Episode of Facial Weakness – OSCE Case

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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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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?


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?


Did you have any sensory disturbances or abnormal sensations?


Did you have any visual disturbances or loss of vision?


Did you have a headache?


Did you have any nausea or vomiting?


Did you have any dizziness or lightheadedness?

โ€I felt light-headedโ€

Did you have difficulty with walking or balance?


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?


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


  • 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



  • 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 


Dr Jess Speller


  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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