History Taking · Foundation · Neurology

Acute Facial Weakness

Practise this PLAB 2 history taking station on Bell's Palsy. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Ms Sarah Mitchell, a 42-year-old woman, presented three days ago with sudden onset facial drooping affecting the left side of her face. She appears anxious. Please take a focused history to differentiate the cause of facial weakness and discuss management.

Background notes: PMH: Migraine, Well-controlled hypertension

What this station tests

  • Distinguishing LMN from UMN facial weakness: forehead involvement (LMN, Bell's) versus forehead sparing (UMN, stroke)
  • Excluding Ramsay Hunt syndrome: no ear vesicles, no otalgia, no hearing loss or vertigo
  • Excluding stroke: no limb weakness, no speech difficulty, no sensory loss, symptoms confined to facial nerve
  • Eye care as a critical management priority: artificial tears, lubricating ointment, taping at night to prevent corneal damage
  • Prognosis counselling: most patients recover fully within 3 months, with significant improvement often visible within 2 to 3 weeks

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Acute facial weakness requires the candidate to distinguish lower motor neuron (LMN) from upper motor neuron (UMN) patterns immediately, because UMN suggests stroke and changes management entirely. The key question is whether the forehead is involved. Ms Mitchell is 42, presenting three days after sudden-onset left facial drooping. She is terrified this is a stroke. Open with: 'I can see you're worried. Tell me exactly what happened and when you first noticed it.' Assess the pattern before reassuring.

Core approach

Establish the LMN pattern. Ms Mitchell cannot raise her left eyebrow, cannot close her left eye fully, her mouth droops on the left, and she cannot puff her cheeks on the left. This is complete hemifacial weakness including the forehead, which is the LMN pattern (Bell's palsy). UMN (stroke) spares the forehead because it receives bilateral cortical innervation. This distinction is the single most important clinical finding.

Exclude Ramsay Hunt syndrome. Ask about ear pain (none), vesicles in or around the ear (none), hearing loss (none), and vertigo (none). Ramsay Hunt (varicella zoster reactivation in the geniculate ganglion) presents with LMN facial palsy plus vesicles and severe otalgia, and requires antiviral treatment in addition to steroids.

Exclude stroke features. No limb weakness, no speech difficulty, no sensory loss, no visual disturbance, no headache. Symptoms are limited to the facial nerve distribution. These negatives are as important as the positives.

Associated features supporting Bell's palsy: slight taste change on the left side of her mouth (chorda tympani involvement), mild sensitivity to loud noises (stapedius involvement). Her left eye feels dry and scratchy because it does not close fully (corneal exposure risk).

ICE: She is terrified this is a stroke (her father had one). She has a wedding in 6 weeks where she is a bridesmaid, and she is devastated about her appearance. She wants to know if her face will recover.

Closing and safety netting

For Bell's palsy, the closing should provide reassurance based on the clinical findings, start treatment, and address eye care. 'Ms Mitchell, this is not a stroke. The pattern of weakness affects your entire left face including your forehead, which tells me this is Bell's palsy, a condition where the facial nerve becomes inflamed. The good news is that most people recover fully, usually within weeks to months.'

Treatment: prednisolone 50mg daily for 7 days, ideally within 72 hours of onset (she is at day 3, so still within the window). No antiviral is needed unless Ramsay Hunt is suspected. Eye care is critical: artificial tears during the day, lubricating ointment at night, tape the eye closed at night to prevent corneal damage from incomplete closure. Explain that corneal ulceration is the main complication risk.

Address her wedding concern with honesty and hope: 'Most people see significant improvement within 2 to 3 weeks, and the majority recover fully within 3 months. At 6 weeks, there is a good chance of substantial improvement.' Safety net: 'If the weakness spreads to other parts of your body, you develop weakness in your limbs, or the eye becomes red and painful, come back immediately.'

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for bell's palsy. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: LMN versus UMN pattern established (forehead involvement confirmed). Ramsay Hunt excluded (no vesicles, no otalgia). Stroke excluded (no limb weakness, no speech difficulty). Onset timing established (day 3, within steroid window). Associated features identified (taste change, hyperacusis, dry eye).

Costs marks: Not checking forehead. Not asking about ear symptoms. Not excluding stroke features. Not establishing timing relative to steroid window.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Prednisolone 50mg for 7 days started within 72 hours. Eye care: artificial tears, ointment at night, taping. Correct decision not to add antiviral (no Ramsay Hunt features). Accurate prognosis discussion. Safety netting for red flags (spread of weakness, eye redness).

Costs marks: Not starting steroids within the window. No eye care. Adding unnecessary antiviral. Incorrect prognosis (either falsely reassuring or unduly pessimistic). No safety netting.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Firm reassurance that this is not a stroke. Addressing the wedding concern with honest hope (significant improvement likely by 6 weeks). Acknowledging the impact on her appearance and self-esteem. Empathic response to her father's stroke history and her fear.

Costs marks: Hedging the stroke reassurance. Dismissing the wedding concern. Not acknowledging the cosmetic impact. Being overly clinical about a condition with significant psychosocial impact.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not examining or asking about the forehead. The distinction between LMN and UMN is the forehead. If the forehead is involved (cannot raise eyebrow, cannot wrinkle forehead), it is LMN. Candidates who do not specifically check forehead movement cannot make this critical distinction.
  2. Not asking about ear pain and vesicles. Ramsay Hunt syndrome requires antiviral treatment (aciclovir) in addition to steroids. Missing it means undertreating. Candidates must ask about ear symptoms in every acute facial palsy.
  3. Not addressing eye care. The eye that cannot close fully is at risk of corneal exposure, drying, and ulceration. This is the main complication of Bell's palsy. Candidates who prescribe steroids but do not discuss eye protection miss a key management point.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the bell's palsy history in this PLAB 2 station?

Acute facial weakness requires the candidate to distinguish lower motor neuron (LMN) from upper motor neuron (UMN) patterns immediately, because UMN suggests stroke and changes management entirely. The key question is whether the forehead is involved. Ms Mitchell is 42, presenting three days after sudden-onset left facial drooping.

What are examiners marking in this bell's palsy station?

Marks are won for: LMN versus UMN pattern established (forehead involvement confirmed). Ramsay Hunt excluded (no vesicles, no otalgia). Stroke excluded (no limb weakness, no speech difficulty). Marks are lost for: Not checking forehead. Not asking about ear symptoms. Not excluding stroke features. Not establishing timing relative to steroid window.

What is the most common mistake candidates make in this bell's palsy station?

Not examining or asking about the forehead. The distinction between LMN and UMN is the forehead. If the forehead is involved (cannot raise eyebrow, cannot wrinkle forehead), it is LMN.

How do I prepare for this station if I have not managed bell's palsy in clinical practice?

Structure beats experience here. Focus on excluding Ramsay Hunt syndrome: no ear vesicles, no otalgia, no hearing loss or vertigo. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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