The physical examination is vital in assessing a patient’s presenting symptom, especially when the symptom is dermatologic in nature. However, if the dermatologic examination shows no abnormality on presentation, further measures must be completed to illicit such symptoms. In our patient, this involved provoking the physical examination finding through exercise.Case Presentation
A 26-year-old woman with a medical history of asthma and hypothyroidism presented to her primary physician for what she described as an unusual rash on the left side of her face for the past 18 months. She described asymmetric erythema and sweating involving the left forehead, cheek, and chin that would appear intermittently and were often exacerbated by warm showers or exercise. These episodes lasted for 30 minutes to a few hours and had been increasing in duration and degree of erythema during this 18-month interval. She denied pruritus, pain, or visual changes. She denied alcohol, illicit drug, or tobacco use. There was no family history of autoimmune, connective tissue, or malignant disorders, or a history of similar symptoms.
Assessment
Dermatologic examination initially revealed no apparent erythema or skin lesions. After provocation with exercise on a treadmill, her examination revealed a confluent erythema, without separate patches or papules noted over the distribution of the left hemiface (Figure 1). This erythema ended sharply in the midline of her face. On neurologic examination, cranial nerves were intact. Specifically, there was no facial droop, lid lag, decreased sensation, or pupillary changes.
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— Kellee Oller, MD, Kimberley Cao, MD, Jim Parkerson, DO, Jose Lezama, MD
This article originally appeared in the April 2011 issue of The American Journal of Medicine.
