Episode of Facial Weakness – OSCE Case

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Introduction

A 68-year-old man attends the emergency department following an episode of facial weakness. Work through the case to reach a diagnosis.

UK Medical Licensing Assessment (UKMLA)

This clinical case maps to the following UKMLA presentations:

  • Facial weakness
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History

Presenting complaint

“It’s settled down now but I had this really weird episode earlier where my face went all weak and numb”

History of presenting complaint

How long ago did this happen?

โ€œAbout 1 hour agoโ€

What were you doing at the time?

โ€œI was shopping with my daughterโ€

Can you describe in your own words what you felt

โ€œMy face felt weak and numb and overall I felt uneasyโ€

Did anyone else notice your symptoms?

โ€œMy daughter noticed I was slurring my wordsโ€

Did you lose consciousness?

โ€Noโ€

Have your symptoms changed since they first began?

โ€œIt fully resolved 20mins agoโ€

Has anything like this ever happened before?

โ€œI had a similar episode 2 years ago. It also resolved on its own with no lasting effectsโ€

Did you have any other symptoms at that time?

โ€œPalpitations in my chest and lightheadednessโ€

Other parts of the history

Did you have any weakness or clumsiness in your arms or legs?

โ€œNoโ€

Did you have any sensory disturbances or abnormal sensations?

โ€Noโ€

Did you have any visual disturbances or loss of vision?

โ€Noโ€

Did you have a headache?

โ€Noโ€

Did you have any nausea or vomiting?

โ€Noโ€

Did you have any dizziness or lightheadedness?

โ€I felt light-headedโ€

Did you have difficulty with walking or balance?

โ€Noโ€

Do you have any medical conditions?

“Type 2 diabetes, high blood pressure, high cholesterol, anxiety and an underactive thyroid”

Do any illnesses run in the family?

“My dad died from a heart attack in his late 60s. And a lot of us have problems with our blood pressure and cholesterol.”

Do you smoke?

โ€œYesโ€

How much do you smoke?

โ€œI smoke a pack every dayโ€

How often do you smoke?

โ€œIโ€™ve smoked for 25 yearsโ€

What is your diet like?

โ€œMost of my meals are takeaways and I often snack on sugary foods which I know I shouldn’t with my diabetesโ€

Do you exercise?

โ€œI try to go for a 10 minute walk once a weekโ€


Clinical examination

FAST assessment:

  • Facial droop: Assess for asymmetric facial weakness by asking the patient to smile and lift eyebrows (forehead sparing lesion)
  • Arms: Assess for pronator drift
  • Speech: Assess for speech disturbances (expressive dysphasia, slurred speech)
  • Time: Define the time course of the symptoms

Examination findings

  • HR 90, RR 16, BP 164/94, Oxygen saturation 96% on air, Temperature 36.7oC
  • Pulse is irregular
  • Heart sounds normal
  • No carotid bruits on neck auscultation
  • All 12 cranial nerves intact
  • No facial weakness
  • No visual field loss
  • Normal tone, reflexes, and coordination through peripheral neurological examination
  • Strength 5/5 bilaterally

Investigations

  • CT head/MRI head within 48 hours
  • Echocardiogram to assess for thrombi in the left atrium
  • Carotid doppler to assess for atherosclerosis and stenosis
  • CT/MR angiogram

Diagnosis


Management

  • Smoking cessation
  • Management of underlying conditions (diabetes, hypertension, hyperlipidemia)
  • Increase level of physical activity (improves blood pressure and glucose control)
  • Dietary modification (low salt, low fat)
  • Reduce alcohol consumption

There are several anticoagulants available. The following could be suitable, depending on the patient and local guidelines: warfarin, apixaban, edoxaban, dabigatran, and rivaroxaban.ย 


Editor

Dr Jess Speller


References

  1. Stroke UK. Stroke statistics. Published in 2022. Available from: [LINK]
  2. NHS. Stroke. Published in 2022. Available from: [LINK]
  3. NICE. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Published in 2019. Available from: [LINK]
  4. Royal College of Physicians. Stroke Guidelines. Published in 2016. Available from: [LINK]

 

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