Cases/Neurology

One Side of Her Face Drooping — Free SCA Practice Case

Pregnant woman with one side of her face drooping

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Catriona Dunn

Age

31 years

Consultation Type

Video

Age

Situation

Video Consultation. Urgent appointment booked by the patient this morning.

Reason for Encounter

"I'm 34 weeks pregnant and the right side of my face has stopped working."

Medical Records

●PMH: Nil. Second pregnancy, 34 weeks, uncomplicated. First baby born at term by normal vaginal delivery. Glucose tolerance test at 26 weeks normal (family history of type 2 diabetes).
●Antenatal BP: 108/66 at booking, 112/68 at 32 weeks. Urine protein nil.
●Medications: Pregnancy multivitamin. Alginate antacid occasionally.
●Allergies: NKDA.
●Social: Lives with her partner and 3 year old daughter. Works from home.

Patient Script

For the friend playing the patient role

Character Overview: You are Catriona Dunn, a 31 year old insurance claims handler who works from home on a computer for most of the day. You live with your partner Callan, who is a train conductor on rotating shifts, and your daughter Elsie, who is 3 and at nursery on weekday mornings. You are 34 weeks pregnant with your second baby and the pregnancy has been straightforward. This morning you found that the right side of your face is not working properly. You are frightened and trying to stay practical. Your nan Morag had a stroke at 70 and was never the same afterwards, and that is the first thing that came into your head. You also read in a pregnancy group last night, before any of this started, that steroids "at the end of pregnancy can stop the baby growing", and you are afraid you will be offered them. You speak quickly when anxious, trail off when you mention the baby, and become calmer when someone is clear with you.

Opening Sentence: "Hello, doctor. I'm 34 weeks pregnant and I woke up with the right side of my face not working. My mouth is dropping and I can't shut my right eye properly. I'm really frightened. Is it something to do with the baby?"

History if Asked (Data Gathering Phase)

●Onset: "I was fine when I went to bed. I got up for the toilet at about half six and it was normal then. When I was brushing my teeth at about seven, water ran out of the right corner of my mouth and I couldn't spit properly. I looked in the mirror and the whole right side was flat. That's about three hours ago. It hasn't got any worse since I rang."
●What is affected: "My mouth won't lift on the right when I smile. My cheek feels heavy and a bit numb, though I can feel you if I touch it. I can't close my right eye all the way, there's a gap."
●Forehead and eyebrow: "Yes, my right eyebrow has dropped lower than the left, and when I tried to raise my eyebrows in the mirror the right side of my forehead stayed smooth. The left went up fine."
●Eye: "It's watery and gritty, like there's sand in it, and the light bothers it a little. No sharp pain, no redness and my vision is clear."
●Ear and hearing: "I've had a dull ache behind my right ear since last night. I thought I'd slept on it funny. Now you say it, noises seem a bit louder on that side, like the dishwasher. My hearing isn't lost."
●Taste and mouth: "Things taste a bit metallic. My mouth feels dry on that side and food gets stuck in my cheek."
●Other limbs and speech: "My arms and legs are fine. I can walk normally and I'm not clumsy. My speech sounds a bit mushy because of my mouth, but I'm finding the words and I'm not slurring them. No double vision, no dizziness and no loss of balance."
●Illness and exposure: "I had a bit of a head cold about ten days ago, nothing since. No fever, no sore throat, no rash or blisters anywhere. No tick bite that I know of, no injury to my head or face, no lumps in my face or jaw, and I haven't travelled."
●Previous episodes: "Never had anything like this before."

Ideas, Concerns, Expectations

Gating note: Catriona does not volunteer any of this. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she hoped for from the call.

●Ideas: She thinks it must be a stroke, because of her nan, and wonders whether the pregnancy has "put pressure on something". "My nan had a stroke and her face went like this. Is it the same thing? Or is it because I'm pregnant?"
●Concerns: Her first fear is a stroke. Her second is that treatment will hurt the baby, because of the post she read. A third, quieter worry is that she will look different when the baby is born and in the photographs. "I've read steroids at this stage can stop babies growing. I'd rather put up with the face than risk the baby. And what if it doesn't come back before I give birth?"
●Expectations: She wants to know what it is, whether she is safe and whether the baby is safe, and whether anything can be done that does not put the baby at risk. She expects to be told to go to hospital. "I just want somebody to tell me it's safe for the baby, and whether it will come back."

If Asked: Medical History and Medications

Gating note: Catriona answers each of these plainly when the doctor asks about it.

●Pregnancy so far: "Second baby, due in about six weeks. It's all been normal. The baby moves as much as usual this morning, same pattern as always."
●Blood pressure and urine: "Always normal at the midwife. It was 112 over 68 about two weeks ago and my urine was clear. I don't have a machine at home. I've not had it checked today."
●Sugar test: "I had the glucose tolerance test at 26 weeks because my mum has type 2 diabetes. It was normal."
●Past health: "Nothing. No migraines, no high blood pressure, no clots, no heart problems, no epilepsy. First baby was a normal delivery at term."
●Medicines: "A pregnancy vitamin and some Gaviscon now and then for heartburn. Nothing else. No eye drops."
●Allergies: "None."
●Mood: "I'm fine in myself, just frightened today. I've never had low mood."

Social History and Lifestyle Impact

●Home and work: Callan is on a shift and not home until about 7 this evening. Elsie is at nursery until 3 o'clock. Catriona works from home on a laptop and her manager is understanding. She starts maternity leave in about four weeks.
●Support: Her mother Aileen lives 30 minutes away and could take Elsie, or drive her to an appointment, if asked.
●Smoking, alcohol, drugs: Never smoked. No alcohol in pregnancy.
●Availability and travel: She can drive and could get to the surgery or the hospital within the hour if asked. She would prefer to be seen after she has sorted Elsie, but would go straight away if told it matters.
●Screens: Her eye is too dry and gritty to look at the laptop for long.

If Asked: Associated Symptoms

Gating note: Catriona answers these only when asked. Every one is negative unless stated.

●If asked about headache: "Only the ache behind my ear. No bad headache and no worst headache of my life."
●If asked about vision changes, flashing lights or blurring: "No, my vision is fine apart from the watering."
●If asked about pain under the ribs, vomiting, or sudden swelling of the face, hands or feet: "No pain under my ribs and no sickness. My ankles swell a bit by the end of the day, that's usual for me, and my rings are fine."
●If asked about fits, fainting or confusion: "No."
●If asked about fever, neck stiffness or feeling unwell: "No, I feel well apart from this."
●If asked about bleeding, leaking or contractions: "Nothing like that. I've had the odd tightening that goes off."
●If asked about swallowing or choking: "Swallowing is fine, but I dribble a bit when I drink."
●If asked to raise her eyebrows, smile or shut her eyes on screen: she declines. "I'd rather you saw me properly than me pulling faces at a screen. Can I come in?"

Responses to Management (The Negotiation Phase)

●
If the doctor explains what this probably is, or that it is not a stroke:
- ●Reaction: Relieved but wary. "How do you know it's not a stroke? My nan's face went the same." She settles if told that her forehead is affected and that her arms, legs and speech are normal. "So what would make you think it was?" She asks how long it will last.
●
If the doctor offers steroid tablets:
- ●Reaction: Hesitant at first. "I read that steroids this late can stop the baby growing. I don't want to do anything that hurts the baby." After an explanation that a short course is not known to harm growth, that most of the drug is broken down before it reaches the baby, and that the benefit is a better chance of full recovery: "Okay. Does it do anything to my blood pressure or sugar? Does the midwife need to know?" She agrees to take it if the doctor tells the midwife and checks her.
●
If the doctor wants to see her in person, take her blood pressure or test her urine today:
- ●Reaction: Anxious then relieved. "Is that because of the baby? I've been fine up to now." She accepts a same day visit, and asks whether to go to the surgery or the maternity unit. She can come after she has dropped Elsie with her mum, within the hour. If told to go to hospital, she asks who will have Elsie.
●
If the doctor explains eye care:
- ●Reaction: Practical questions. "Tape it shut? Won't that hurt? Can't I just put a pad on it?" She asks how often to use drops and for how long, and whether her usual glasses are enough outdoors. "And what if the drops sting?"
●
If the doctor talks about recovery, the birth or her appearance:
- ●Reaction: Tearful for a moment. "Will it be back to normal by the time the baby comes? Will it affect the birth?" If given a realistic answer: "At least I know what to expect. I just don't want to be frightened all the time."
●
If the doctor gives safety netting:
- ●Reaction: Wants specifics. If told only to come back if worse: "Worse how? What would mean I should ring 999 and what would mean the maternity unit?" She repeats the plan back clearly when given symptoms and where to go.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Catriona is 34 weeks pregnant with three hours of right sided facial weakness that includes the brow, no limb, speech or vision symptoms, and a fear that steroids will harm her baby. The station tests telling Bell's palsy from stroke, treating it promptly and safely in pregnancy, protecting the eye, and remembering that the pregnancy makes a blood pressure check part of the assessment.
●The model plan has six parts. Take a focused history that screens for central, ear, infective and pregnancy features. Recognise a lower motor neuron pattern and say what would instead mean a stroke. Arrange examination in person today with blood pressure and urine protein, because a facial palsy cannot be examined by video. Offer oral prednisolone within 72 hours of onset, explaining its safety in pregnancy and sharing care with the midwife. Give eye care advice. Finish with specific safety netting, follow up and referral criteria.
●Acceptable alternatives: starting prednisolone on the history with examination the same day, or starting it after the face to face assessment. Examination at the surgery or at the maternity assessment unit are both reasonable. A short delay to take obstetric or specialist advice is acceptable if the 72 hour window is respected and a plan is stated.

Bell's Palsy and How to Tell It From Stroke

●Bell's palsy is an acute, unilateral, idiopathic facial nerve palsy. NICE Clinical Knowledge Summaries (CKS, last revised February 2023) say the diagnosis is made when no other cause is found. Onset is rapid, within 72 hours, and the weakness affects the upper and lower face, with a drooping brow and mouth and poor eye closure.
●Associated features are ear or postauricular pain in around half of people, taste change, dry mouth, dry or watering eye, and hyperacusis in under 5%. Catriona has the ear ache, a metallic taste, a dry gritty eye and some louder sounds, which supports a facial nerve lesion.
●Sparing of the brow, because the forehead has bilateral cortical supply, suggests an upper motor neuron lesion such as stroke. Limb weakness, facial numbness, speech or vision change, imbalance or other cranial nerve involvement also point away from Bell's palsy. CKS says to arrange immediate emergency admission when stroke is suspected.
●Asking about the brow in the history works on a video call. The examination in person confirms the diagnosis.

Other Causes to Exclude

●CKS lists atypical features needing referral to exclude another diagnosis: gradual progression, pain in the facial distribution, hearing loss, a parotid mass, fever or systemic illness, dizziness, double vision, difficulty swallowing, bilateral signs, a previous episode, and vesicles.
●Vesicles around the ear or mouth suggest herpes zoster (Ramsay Hunt syndrome), which needs a different approach. Facial or jaw lumps suggest parotid disease. Bilateral palsy, tick exposure or travel raises Lyme disease or sarcoidosis.
●The examination covers cranial nerves, otoscopy, tuning fork tests, the parotid, the skin of the head and face, and the eyes. Routine blood tests and imaging are not needed in primary care for a typical new palsy.

Pregnancy: Why Blood Pressure and Urine Matter

●CKS lists current pregnancy or recent delivery as something to ask about, and says the course of Bell's palsy is typically more severe in pregnancy, with complete paralysis and incomplete recovery more likely. Because pregnancy is a setting where raised blood pressure and pre-eclampsia can arise at 34 weeks, a blood pressure and urine check belongs in the assessment of any acute neurological symptom, whatever the cause of the palsy.
●Pregnancy and the weeks after birth also carry a higher risk of stroke, cerebral venous thrombosis and eclampsia, so the history for headache, vision, fits and limb signs matters.
●Check blood pressure and urine protein today, because the last reading was two weeks ago. NICE NG133 (Hypertension in pregnancy, updated April 2023) says women with gestational hypertension need full assessment in a secondary care setting, and tells women to see a healthcare professional immediately for severe headache, visual disturbance, severe pain just below the ribs, vomiting and sudden swelling of the face, hands or feet. A raised reading, positive protein or any of these symptoms needs same day maternity assessment under the local pathway.

Prednisolone: Dose, Timing and Safety in Pregnancy

●CKS says that for people presenting within 72 hours of onset, consider prednisolone. There is no consensus on dose, and the options are 50 mg daily for 10 days, or 60 mg daily for 5 days then reducing by 10 mg a day for a total of 10 days. A Cochrane review found incomplete recovery in 17% of those treated with a corticosteroid against 28% of those untreated, a number needed to treat of 10.
●Early treatment matters. CKS reports full recovery at 6 months or more in 83% of those treated within 72 hours against 72% of those who were not. Catriona is only about three hours in, so there is time for examination and discussion, but not for a week long delay.
●The BNF states that the benefit of corticosteroid treatment in pregnancy outweighs the risk. There is no convincing evidence that systemic corticosteroids increase congenital abnormalities such as cleft palate. Prolonged or repeated courses increase the risk of intrauterine growth restriction, and there is no evidence of it after short term treatment. Of prednisolone crossing the placenta, 88% is inactivated.
●Pregnant women with pre-eclampsia or fluid retention should be monitored closely while on systemic steroids. Plan a blood pressure recheck, ask her to report thirst, passing a lot of urine or other signs of raised sugar, and tell the midwife. Her glucose test at 26 weeks was normal.
●Her fear should be acknowledged. The explanation that matters is that a short course is not known to affect growth, that most of the drug is broken down before it reaches the baby, and that the prolonged or repeated courses she read about are different. Respecting a refusal after a full discussion is acceptable.

Antivirals and Investigations

●CKS states that antiviral treatment alone is not recommended. Combined treatment with a corticosteroid is not routinely recommended because the evidence is insufficient, may be of small benefit, and specialist advice should be sought if it is being considered. Antivirals have a clearer role where Ramsay Hunt syndrome is suspected, which is a separate diagnosis.
●No routine blood tests or imaging are needed for a typical presentation. Urgent imaging or admission is appropriate if features are atypical or stroke is suspected.

Eye Care

●CKS advises keeping the affected eye lubricated, with frequent drops by day and ointment at night, and taping the eyelid closed at bedtime with microporous tape if it will not close. Eye patches are contraindicated because the eye may open under the patch and cause a corneal abrasion. Sunglasses outdoors help, and swimming and dusty places should be avoided.
●Refer to ophthalmology if ocular symptoms such as pain, irritation or itch develop at any time, and give eye care advice while waiting.

Safety Netting, Follow Up and Referral

●Name symptoms and dispositions. Call 999 for new weakness in an arm or leg, speech or vision change, a fit, confusion or sudden severe headache. Contact the maternity assessment unit the same day for severe headache, vision disturbance, pain below the ribs, vomiting, sudden swelling or reduced fetal movements. Seek urgent eye review for eye pain, redness or blurred vision.
●Arrange review in about a week to check improvement, blood pressure and the eye. Most people begin to recover within 2 to 3 weeks and complete recovery usually occurs within 3 to 4 months, although recovery is often slower in pregnancy.
●CKS advises referral to a facial nerve specialist, such as a neurologist or ENT surgeon, if atypical features are present, there is no improvement after 3 weeks of treatment, neurological findings worsen or new ones appear, recovery is incomplete at 3 months, or the diagnosis is uncertain. Uncomplicated cases are not routinely referred. Suspected stroke needs immediate emergency admission, and suspected cancer a suspected cancer pathway referral.
●Share care with the midwife or maternity team, who can plan around the palsy for labour.

Common Mistakes in This Station

●Calling it a stroke or a pregnancy complication without recognising the lower motor neuron pattern, or declaring Bell's palsy without asking about the brow, limbs, speech and ears.
●Making the diagnosis and plan from the video alone, with no examination arranged today.
●Not checking blood pressure and urine, or not telling the midwife or maternity team.
●Refusing steroids because she is pregnant, or giving them without discussing her fear about the baby.
●Letting the 72 hour window pass, or offering an antiviral on its own.
●Advising an eye patch, or giving no eye care advice at all.
●Vague safety netting such as "come back if it gets worse", with no separation of 999, maternity unit and urgent eye review.
●Promising that the palsy will clear before the baby is born.

Mapped to the RCGP curriculum topic: Neurology.

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