Health Assessment

Unilateral Face Numbness

Carnel C. Jackson, DNP, RN, FNP-BC

Case Study

Chief Complaint

“I woke up and I can’t feel the right side of my face.”

Patient Profile

Name: Judith Williams

Age: 36 years old

Gender: female

History of Presenting Illness

J.W. is a 36-year-old woman who presents with sudden onset of weakness and numbness on the right side of the face, beginning approximately 18 hours ago. The patient reports inability to fully close the eye and drooping of the mouth on the right side of her face.* Symptoms have been persistent since onset.*

The patient also reports mild numbness and tingling in the face but denies limb weakness, speech difficulty, dysphagia, vision changes, or gait imbalance.* There is no headache, fever, or recent trauma.* She denies recent travel, tick bites, or rashes.* At the end of the visit, she reports that she had to take her mother to the doctor’s office due to a new rash on her chest and shoulder.*

Past Medical History

  • Seasonal allergies
  • Diabetes mellitus type 2, no medications currently (has not had lab work completed in 4 years)
  • Medications
  • Fluticasone 27.5 mcg/spray – 2 sprays to each nare once daily

Social History

  • Case manager
  • Lives with two children; widow
  • One dog
  • Enjoys weekly hikes with a close friend*
  • Alcohol use: holidays only (2-3x per year)
  • Tobacco smoke: none
  • Illicit Drug use: none

Family History

  • Mother: Hypertension, hyperlipidemia, rheumatoid arthritis, recently diagnosed with shingles*
  • Father: Colon cancer (alive), allergies
  • Maternal grandmother: Hypertension, osteoporosis
  • Maternal grandfather: Hypertension, hyperlipidemia
  • Paternal grandfather: Angina, coronary artery disease
  • Paternal grandmother: Chronic kidney disease, hypertension, coronary artery disease

Review of Systems

  • Constitutional: Denies chills, fever. Reports smell of tobacco smoke.
  • HEENT: Denies postnasal drip, sore throat, hearing impairment,* denies blurred vision, Endorsed right-sided facial numbness and droop,* absence of right nasolabial fold.* Denies recent history of mouth sores or ulcers.*
  • Respiratory: Denies shortness of breath, cough, wheezing.
  • Cardiovascular: Denies chest pain and pedal edema.
  • Gastrointestinal: Denies abdominal pain, tenderness, nausea and emesis. Denies constipation, diarrhea, hematochezia. Denies appetite changes and melena.
  • Derm: Denies breaks in the skin, lesions and rashes.
  • Neurological: Denies headaches, tremors and dizziness. Right-sided facial paresthesia.*
  • Musculoskeletal: Denies weakness in bilateral upper and lower extremities.*
  • Hematologic: Denies easy bruising.

Physical Assessment

Vitals

  • Blood pressure: 124/76 mm Hg
  • Heart rate: 64 bpm
  • Respiratory rare: 14 bpm
  • Temperature: 97.6°F
  • Oxygen saturation: 99% on room air

General Survey

  • General appearance: Alert, oriented, slender male.
  • HEENT: Moist mucous membranes. PERRLA. Thyroid exam normal. Right-sided facial droop with flattening of the nasolabial fold,* drooping of the mouth and eyebrow sagging.*
  • Cardiovascular: Normal rhythm without murmurs. Normal s1 and s2.
  • Respirations: Clear to auscultation bilaterally.
  • Abdomen: Active bowel sounds x4. Nontender on palpation. Nondistended.
  • Derm: Without abrasion or ulceration, without rash, lower extremity stasis dermatitis.*
  • Neurological: No signs of confusion or cognitive impairment. Impaired ability to raise the right eyebrow, close the right eye and inability to make forehead wrinkles.*
  • Extremities: Full passive and active ROM of bilateral upper and lower extremities, 5/5 strength.*

Assessment

Leading diagnosis: Bell’s palsy

Diagnostic Testing

Pending clinician workup.

Review Questions

Click the arrow to expand the section and view the correct answers.

drawing depicting an abnormal nasolabial fold on the right side of the patient’s face.
Identify the nasolabial fold
  1. Please correctly identify where the nasolabial fold is.
    1. The nasolabial fold is between the bridge of the nose and lower eye lid
    2. The nasolabial fold is the area between the nares and the top lip
    3. The nasolabial folds are the lines that run from the sides of the mouth and nose
    4. The nasolabial fold is the line between the bridge of the nose and the eyebrows
Answer:

C) The nasolabial folds are the lines that run from the sides of the mouth and nose. Feedback: The nasolabial folds are the lines that run from the sides of the nose to the mouth.

  1. Which cranial nerve is affected in Bell’s Palsy?
    1. Cranial Nerve III (Oculomotor)
    2. Cranial Nerve V (Trigeminal)
    3. Cranial Nerve VII (Facial)
    4. Cranial Nerve IX (Glossopharyngeal)
Answer:

C) Cranial Nerve VII (Facial)

  1. As part of your cranial nerve assessment, which of the following actions best evaluates the function of the 7th cranial nerve (facial nerve)?
    1. Ask the patient to shrug their shoulders and turn their head against resistance
    2. Ask the patient to stick out their tongue and move it side to side
    3. Ask the patient to smile, raise their eyebrows, and puff out their cheeks
    4. Test sensation on the forehead, cheeks, and jaw
Answer:

B) Ask the patient to smile, raise their eyebrows, and puff out their cheeks

Feedback: Ask the patient to smile, raise their eyebrows, and puff out their cheeks.

  1. A patient presents with acute facial weakness, arm weakness, and difficulty speaking. What is the most appropriate next step?
    1. Start corticosteroids immediately
    2. Perform a thorough cranial nerve exam
    3. Order an urgent CT or MRI brain scan
    4. Prescribe antivirals for suspected Bell’s Palsy
Answer:

C) Order an urgent CT or MRI brain scan. Feedback: Order an urgent CT or MRI brain scan. If symptoms include limbweakness or speech difficulty, stroke should be suspected, and brain imaging is warranted immediately.

  1. Which of the following signs is more characteristic of Bell’s Palsy rather than stroke?
    1. Presence of hemiparesis
    2. Difficulty closing the eye on the affected side
    3. Asymmetrical smile with intact forehead movement
    4. Sudden onset of unilateral numbness
Answer:

B) Difficulty closing the eye on the affected side. Feedback: Difficulty closing the eye on the affected side. Bell’s Palsy typically affects the entire side of the face, including the eye muscles, causing the inability to fully close the eye, whereas stroke typically spares the upper face.

  1. Which of the following conditions mimics Bell’s Palsy but is typically associated with a vesicular rash in the ear or mouth?
    1. Lyme disease
    2. Ramsay Hunt syndrome
    3. Myasthenia gravis
    4. Guillain-Barré syndrome
Answer:

B) Ramsay Hunt syndrome. Feedback: Ramsay Hunt syndrome is caused by varicella-zoster virus reactivation and presents with facial paralysis like Bell’s Palsy, but it also includes a vesicular rash in the external ear or mouth and may cause severe pain.

  1. Which of the following differential diagnoses may cause bilateral facial weakness?
    1. Stroke
    2. Tumor
    3. Herpes zoster
    4. Lyme disease
Answer:

D) Lyme disease. Feedback: Lyme disease is more likely to cause facial weakness to both sides of the face when compared to a cerebrovascular accident, tumor, or herpes zoster.

  1. Which of the following clinical features is more characteristic of trigeminal neuralgia than Bell’s palsy?
    1. Sudden onset of unilateral facial weakness
    2. Inability to raise the eyebrow on the affected side
    3. Sharp, electric-shock-like facial pain triggered by chewing or touching the face
    4. Loss of taste sensation on the anterior two-thirds of the tongue
Answer:

C) Sharp, electric-shock-like facial pain triggered by chewing or touching the face. Feedback: Trigeminal neuralgia typically presents with paroxysmal facial pain, often triggered by stimuli like brushing teeth or chewing. Bell’s palsy involves motor dysfunction, not sharp pain.

  1. Which of the following may have increased the risk of Bell’s palsy? Select all that apply:
    1. A. Personal history of diabetes mellitus type 2
    2. B. Recent exposure to herpes zoster rash
    3. C. Family history of rheumatoid arthritis
    4. D. No regular follow-up care
    5. E. All of the above
Answer:

Answer: A), B) Personal history of diabetes mellitus type 2, recent exposure to herpes zoster rash

Feedback:

  • Personal history of diabetes mellitus type 2, microvascular ischemia.
  • Recent exposure to herpes zoster rash increases risk of reactivation.

Clinical Pearls

* All areas with asterisks are highlighted for a patient with this chief complaint.

Bell’s Palsy:

  • Acute, unilateral facial paralysis due to inflammation or compression of the facial nerve, CN VII.
  • Most often idiopathic and self-resolved but may be linked to HSV reactivation
  • If patient can still raise the eyebrows symmetrically-think central lesion (cerebrovascular accident) and not Bell’s palsy
  • Ear pain often precedes weakness
  • History of diabetes can increase risk of Bell’s palsy due to high blood glucose levels

Physical findings:

  • Flattened nasolabial fold
  • Drooping of the mouth
  • Inability to raise the eyebrows, close eyelid fully, and puff out the cheeks

Diagnostics:

  • Imaging is typically not required
  • If atypical symptoms: consider MRI brain and Lyme titers

References

Gilden, D. H., & Tyler, K. L. (2024). Bell’s palsy: Pathogenesis, clinical features, and diagnosis. In J. L. Bennett (Ed.), UpToDate. UpToDate. https://www.uptodate.com/contents/bells-palsy-pathogenesis-clinical-features-and-diagnosis

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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