Stroke or Bell's Palsy? Facial Droop, Slurred Speech and Afib

75 yo AAF was admitted to the hospital because his daughter noticed that the patient woke up with a left facial droop and slurred speech.

She called 911 because she suspected a stroke. On arrival in ER, the patient's EKG showed a new onset Afib with a rate of 75 bpm.

PMH:
ESRD on HD, HTN, DM, severe AS with 0.6 cm2 deemed inoperable due to ESRD.

CT of the head showed an occipital stroke of unknown age (new since the previous CT 4 years ago), atrophy and ventriculomegaly.

Is it a stroke?
Physical exam was remarkable for left facial drooping and slurred speech (dysarthria).

What is your diagnosis?
Stroke
TIA
Bell's palsy

Diagnosis:
Patient was unable to wrinkle his forehead which was indicative of LMN palsy of CN 7 (Bell's palsy).

Remember:
U MN damage
U pper face is OK (patient is able to wrinkle his forehead)

LMN damage = patient is unable to wrinkle his forehead (our patient)

The exam for CN 7 palsy is remembered by the mnemonic COWS:
C lose your eyes
O pen (Dr. tries to open patient's eyes)
W rinkle your forehead
S mile
Don't ask "show me your teeth" because a common reply is "I don't have any teeth!".


Image source: Yale University.

The rest of the exam was unremarkable apart from a high pitched 4/6 ESM in the aortic area radiating to the carotids (murmur of the previously known 0.6 cm2 AS).

One important point on the physical exam of an ESRD patient?
What is the HD access? In this patient the access was a LUE AV fistula with a good thrill and pulse.

What to do?
The patient was started on Lovenox 1 mg/kg SQ BID for Afib anticoagulation with a plan to start Coumadin the next day.

Acyclovir and Prednisone were started for his Bell's palsy. No evidence of herpetic skin or ear canal lesions was found.

What about the dose of the medications?
Exactly. You cannot just start Lovenox and Acyclovir. You have to adjust the dose in a HD patient.

Lovenox dose was reduced by 50% and it was given QD (1 mg/kg SQ QD).

Acyclovir was given BID instead of 5 times per day (q 4 hr).

What happened?
The patient had a persistent bleeding from the arteriovenous fistula (AVF) for HD which resolved only after Lovenox was stopped.

He was sent home on ASA, Acyclovir and Prednisone.

What did we learn from this case?
Not all cases with a facial droop and slurred speech are caused by stroke. Bell's palsy is relatively common. Always check if the medication you are prescribing to your patient has to be adjusted for his creatinine clearance (CrCl).

Related
They Called Him "Mac". Emergiblog describes the story of her father's stroke and its aftermath.

Published: 09/01/2004
Updated: 04/10/2008