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Patient Details

Refined clerking (38 days ago 01:41)

Refined clerking Fri 27 February 2026 01:41

Last Modified: 38 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Right-sided facial droop

History of Presenting Complaint:
Mr Temblett presented with a right-sided facial droop associated with a background headache. He reported a 1-2 week history of intermittent right-sided headaches, dull in character, rated 5/10 in intensity, managed with paracetamol. The facial droop was noted in the context of an inability to fully close the right eye. There was no sudden onset or thunderclap quality to the headache, and it was no worse than his background headaches.

Approximately 4 weeks prior to presentation, he developed right-sided otalgia with brown fluid discharge from the right ear, which persisted for approximately 9 weeks. No recent head trauma was reported.

Past Medical History:
• Recurrent episodes of presyncope/bradycardia (under cardiology follow-up)
• Under gynaecology follow-up (details not available)

Drug History:
• Paracetamol 1g PO PRN (self-medicating for headaches)

Allergy History:
• NKDA

On Examination:
Generally well-appearing.

• Neurological:
  - Cranial nerves: Right-sided lower motor neurone facial nerve palsy. Unable to fully close right eye. Right eyebrow elevation markedly reduced with absent forehead wrinkling on the right, consistent with forehead involvement. Mild right-sided facial droop. Tongue midline. Speech mildly dysarthric. Visual fields full to confrontation bilaterally. Extra-ocular movements intact. Pupils not documented.
  - Upper limbs: Power and coordination intact bilaterally. Finger-nose testing intact bilaterally.
  - Lower limbs: Power intact bilaterally. Heel-shin testing intact.
  - Sensation: Intact to light touch in upper and lower limbs and face bilaterally.
  - Cognition: Oriented to month. Object naming and reading intact.
  - Proprioception and balance: Intact.

Investigations:
• Blood tests: Pending (requested in A&E)

Impression:
Right-sided lower motor neurone facial nerve palsy (Bell's palsy), likely secondary to recent right-sided otitis externa with brown exudate.
Differential Diagnoses: Stroke excluded clinically on the basis of forehead involvement (indicating a peripheral lower motor neurone lesion rather than a central lesion), absence of limb weakness, and intact proprioception and cerebellar function. Ramsay Hunt syndrome considered given recent ear symptoms.

Management Plan:
1. Monitor in A&E.
2. Blood tests to exclude alternative or systemic causes of facial nerve palsy.
3. Commence a course of high-dose corticosteroids to reduce inflammation of the facial nerve.
4. CT head or further imaging to be considered at the discretion of the senior review.
5. Patient advised regarding the diagnosis of Bell's palsy, likely triggered by recent ear infection, and the expected clinical course.
6. Senior review (registrar/consultant) to confirm management plan prior to discharge.
7. Consider ophthalmology input or eye care advice given incomplete right eye closure (corneal protection).
8. Discharge with outpatient follow-up if clinically appropriate following senior review.

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Refined clerking Fri 27 February 2026 01:41

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