Acute Onset Facial Droop

Vital Signs

• Temperature: 98.3 °F, axillary

• Blood Pressure: 132/76 mmHg

• Heart Rate: 81 beats per min – normal sinus rhythm on telemetry

• Respiratory Rate: 11 breaths per min

• Pulse Oximetry: O ₂ saturation of 99% on room air

Focused Physical Examination

A quick exam revealed a well-built middle-aged man in no acute distress resting comfortably in his bed. Upon auscultation, his lungs were clear, and his heart sounds were regular. There was a pronounced left-sided facial droop. The patient was not able to raise his left eyebrow. The left eye did not fully close when the patient was instructed to close his eyes tightly. There was an absence of wrinkles noted on the left side of the forehead. The remaining cranial nerve testing did not reveal any abnormalities. He was alert and orientated, had full strength in his upper extremities and left lower extremity. His right lower extremity demonstrated 4/5 strength that was limited secondary to pain. Finger-nose-finger testing was intact. He denied any headaches, vision problems, or dizziness. He reported that he had some eye dryness and irritation over the last two days, but he attributed this to being in the hospital and undergoing his knee replacement. His National Institutes of Health (NIH) score was three.

Interventions

Given the neurological exam findings, a stroke alert was called, and expert stroke team consultation was sought. A stat computed tomography (CT) of the head was done, which did not show any acute hemorrhage. Stat magnetic resonance imaging (MRI) of the brain was obtained and was negative for any acute infarcts. A presumptive diagnosis of Bell palsy was made, and the patient was started on 60 mg of oral prednisone; he received his first dose after the imaging had been reported. Due to the patient being unable to close his left eye fully, artificial tears and an eye patch were ordered to prevent ocular injury.