Solve the Medical Riddle: One Side of Her Face Suddenly Drooped and She Couldn’t Smile or Close Her Eye, First Week

By Marie Savard MD

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

We’ll start this week by letting you know what the patient told her PCP and how the doctor proceeded with the examination. Next week, the PCP and a neurologist will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient Reports Her Symptoms

Marjorie, age 58, asked for an emergency appointment with her doctor when the left side of her face suddenly started drooping and she couldn’t smile or close her left eye.

As always in ThirdAge Medical Riddles, the doctor uses the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

This week, we’ll learn what Marjorie told her PCP:

“Thank you for agreeing to see me right away! If you had been too busy, I was going to go to urgent care or the emergency room. I’m so scared! When I woke up this morning, I felt perfectly fine. Then while I was having my coffee and checking my email before getting ready to go to work, the left side of my face started to feel weird. About an hour later, after I took my shower, I looked in the bathroom mirror. I tried to smile, but my face was lopsided and I couldn’t totally close my left eye. Yikes! I yelled to my husband that maybe I was having a stroke and he came running. He was freaked out by what he saw. As you know I’m a fourth grade teacher. Currently, I’m teaching summer school. I called the school and said they had to get a sub for me. Then I called you right away. After I got the appointment, my husband insisted on driving me here. He called his office and said he’d be late. He’s out in the waiting room now. Maybe you should ask him to come in and help me make sense of what you tell me. I am so rattled that I’m afraid I won’t process everything you say!”

The doctor did call Marjorie’s husband into the examining room so he could help her with asking questions. He had his tablet with him and he took notes, which was very good idea. Marjorie visibly relaxed when she realized her husband would have a record of what went on during the visit.

The doctor told Marjorie that she was right to be concerned because, although unlikely, the cause of paralysis could be a stroke or a brain tumor. Still, the doctor quickly reassured Marjorie that conditions like brain tumors are likely have a more subtle onset and that symptoms may seem to come and go. The doctor also said that although a stroke is sudden, it is rarely limited to facial nerve distribution – that is, the face muscles — and almost always would involve an upper or lower extremity on the opposite side of the body. Marjorie had left facial involvement, for which a stroke would mean paralysis on the right side of body because the left side of brain controls the right side of body.

The doctor took a thorough history, confirming that the onset was sudden, there had been no prior weird episodes, no headaches, no facial pain, and no swallowing or other neurologic problems. Since Marjorie lives in the Northeast, the doctor asked about possible tick exposure that could have led to Lyme disease. Marjorie said she didn’t believe she had been exposed to ticks.

Next the doctor asked about recent upper respiratory tract symptoms. Marjorie said she hadn’t had any. Also, Marjorie was not diabetic. Marjorie did say she had cold a few weeks before this happened, but it was mild and cleared up quickly. Marjorie said a lot of the students in her summer school class had colds so she wasn’t surprised she caught one even though she is careful to wash her hands and use hand sanitizer.

During the physical exam, the doctor did a complete neurological exam that showed signs limited to Marjorie’s left facial nerve only, with no cranial nerve or other nerve findings. Marjorie had no sensory problems.

After the doctor finished taking the history and doing the physical, she suspected she had her diagnosis for Marjorie’s condition. However, she recommended a referral to a neurologist to be absolutely certain . . .

To be continued . . .

Come back to ThirdAge.com next Thursday to learn how the neurologist continued the quest for a correct diagnosis of Marjorie’s condition . . .

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.