One Side of His Face Drooping — Free SCA Practice Case
Man who woke with one side of his face drooping
Station Timer
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
Materials for Candidate
Please review before starting the consultation
Full Name
Neil Barrett
Age
42 years
Consultation Type
VideoAge
42
Situation
Video Consultation. The patient has booked an urgent appointment.
Reason for Encounter
"I woke up this morning and one side of my face isn't working — it's drooping and I can't close my eye. I'm scared I'm having a stroke."
Medical Records
- ●PMH: Nil.
- ●Medications: None.
- ●Allergies: NKDA.
- ●Recent contact: Nil.
Patient Script
For the friend playing the patient role
Character Overview: You are Neil, a 42-year-old lorry driver who lives alone. This morning you woke and noticed the left side of your face was not working — your mouth droops, only the right side moves when you smile, and you cannot fully close your left eye. You can raise your right eyebrow but not your left. You have no other symptoms. You are frightened this is a stroke, and worried about whether you can work and drive. You are anxious and want to know what is happening and whether it can be treated.
Opening Sentence: "Doctor, I woke up this morning and the left side of my face has just… stopped working. My mouth's drooping, I can't smile properly on that side, and I can't close my left eye. I'm really scared this is a stroke."
History if Asked (Data Gathering Phase)
- ●The weakness: "It's the whole left side of my face. My mouth droops, I can't smile on that side, and I can't close my left eye properly."
- ●The forehead (if asked/observed): "I can raise my right eyebrow, but not my left — the left side of my forehead won't move." (Forehead involved — lower motor neuron.)
- ●Onset: "I woke up with it this morning. It was fine last night."
- ●Other symptoms: "No — my arms and legs are fine, my speech is normal, my vision's okay, no dizziness or balance problems."
- ●What he's worried about: "I'm terrified it's a stroke. And I don't know if I can drive or go to work like this."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.
- ●Ideas: Neil is convinced this might be a stroke. "In my head this is a stroke — that's what a drooping face means, isn't it?"
- ●Concerns: He is frightened it is something serious and permanent, and worried about work and driving (he is a lorry driver who lives alone). "I'm scared it's serious and permanent. And I'm worried sick about work and driving."
- ●Expectations: He wants to know what it is and whether it can be treated. "I just want to know what's happening and if it can be fixed."
If Asked — Stroke, Bell's, and Other-Cause Screen
The patient answers these only when directly asked; on video he can perform guided movements.
- ●If asked to raise both eyebrows / wrinkle the forehead (guided): "I can raise the right eyebrow but the left side of my forehead won't move at all." (Forehead NOT spared → lower motor neuron → Bell's, not stroke.)
- ●If asked about limb weakness, numbness, or clumsiness: "No, my arms and legs are completely normal."
- ●If asked about slurred speech or difficulty with words: "No, my speech is fine."
- ●If asked about visual disturbance, dizziness, or loss of balance: "No, none of that."
- ●If asked about facial pain, a rash, blisters, or earache (Ramsay Hunt): "No pain, no rash or blisters, no earache."
- ●If asked about hearing changes / sounds seeming too loud (hyperacusis): "Now you mention it, sounds seem a bit louder on that side."
- ●If asked about difficulty chewing, drooling, or a dry/watery eye: "A bit of drooling on that side, and my left eye feels dry and watery."
- ●If asked about fever, headache, or neck stiffness: "No fever, no headache, no stiff neck."
- ●If asked about lumps around the face/jaw, weight loss, night sweats (parotid tumour): "No lumps, no weight loss or night sweats."
- ●If asked about social history: "Non-smoker, occasional drink, I live alone and I'm a lorry driver."
Responses to Management (The Negotiation Phase)
- ●If the Doctor explains this is Bell's palsy, not a stroke: "So it's not a stroke? How can you tell?" (The tested point is explaining the forehead-involvement discriminator — that stroke usually spares the forehead — reassuringly and accurately.)
- ●If the Doctor arranges urgent in-person examination: "You need to see me in person to be sure? Okay." (The tested point is arranging a face-to-face examination to confirm and exclude other causes.)
- ●If the Doctor offers steroids: "Steroid tablets will help it recover? How soon do I need to start?" (The tested point is early high-dose corticosteroids, ideally within 72 hours.)
- ●If the Doctor explains eye care — critical: "What do I do about my eye if I can't close it?" (The tested point is eye protection to prevent corneal damage.)
- ●If the Doctor addresses work and driving: "Can I drive my lorry? Can I work?" (The tested point is sensible advice about driving/occupation given impaired eye closure.)
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Bell's Palsy vs Stroke — "Upper Spares Upper"
- ●The key discriminator in acute unilateral facial weakness is forehead involvement: Bell's palsy is a lower motor neuron palsy affecting the whole side of the face, including the forehead (cannot raise the eyebrow/wrinkle the forehead). A stroke is an upper motor neuron lesion that usually spares the forehead (the eyebrow can still be raised), because the upper face has bilateral cortical innervation.
- ●Forehead sparing, or any other neurological deficit (limb weakness, speech), means treat as a stroke — an emergency (999).
Screen for Other Causes
- ●Screen for Ramsay Hunt syndrome (herpes zoster oticus — ear pain, vesicular rash, hearing changes), parotid tumour (facial mass, weight loss), infection (fever, headache, neck stiffness), Lyme disease, and trauma.
Early Corticosteroids
- ●Bell's palsy is treated with early oral corticosteroids (e.g. prednisolone, a high-dose ~10-day course), ideally within 72 hours of onset, which improves the likelihood of complete recovery.
Eye Care Is Critical
- ●Because the eye cannot close, there is a risk of exposure keratopathy/corneal damage. Advise lubricating drops by day, ointment and taping/padding the eye at night, and eye protection (especially in dusty/occupational settings), with urgent ophthalmology review for a painful/red eye or visual change.
Antivirals
- ●Antivirals may be considered in severe cases or where Ramsay Hunt is suspected (per guidance/specialist advice), usually alongside steroids.
Prognosis, Referral, and Driving
- ●Most cases recover, often within weeks to months. Refer (ENT/neurology) for atypical features, bilateral palsy, no improvement, or diagnostic doubt. Consider driving/occupational implications of impaired eye closure/vision — important for professional drivers.
Safety-Netting
- ●Safety-net for new stroke features (→ 999) and eye pain/redness/visual change (→ urgent eye review), and arrange follow-up.
Common Candidate Mistakes in This Case
- ●Getting the forehead sign wrong: failing to assess or misinterpreting forehead involvement, and so mislabelling Bell's vs stroke.
- ●Missing when it is a stroke: not recognising that forehead sparing or other deficits mandate the emergency stroke pathway.
- ●Omitting eye care: the critical, sight-protecting omission.
- ●Not starting steroids early: missing the 72-hour treatment window.
- ●Ignoring driving/occupation: overlooking the implications for a professional driver, and weak safety-netting.