Renaldo Saldana: A 58-Year-Old Male With Left-Sided Facial Pain and Rash

Renaldo Saldana

Renaldo Saldana is a 58 y/o waiter with the chief complaint of, “My left forehead is killing me.” Renaldo went on to say that he wouldn’t have bothered coming in just for the pain, which had been present for a couple of days, but when he developed a rash on his left forehead, his boss told him he couldn’t wait tables and would have to wash dishes until the rash went away. I asked Renaldo if he had anything like this happen before. He shook his head and responded, “You know me, Doc, I am happy and healthy, but I am really worried about this rash. The damn forehead pain was bad enough, but when I woke up and saw this rash, it really freaked me out!” He continued, “Doc, the crazy thing is that the rash wasn’t there when I went to bed. I am positive about this because I went to look in the bathroom mirror to see if I could see why my forehead was hurting, and there was nothing there. I get up this morning, and I see a couple of little blisters over my eye. Now the damn rash is spreading and my boss won’t let me work. I’m pretty tough, but this really has me worried because if I don’t work, I don’t eat. The other crazy thing is it hurts when I try to comb my hair. What is that all about? Do you think I got bit by one of those brown recluse spiders?”

I asked Renaldo about any antecedent trauma to the forehead and he just shook his head. “Doc, this kind of snuck up on me. Like I said, at first, my forehead began aching and then I woke up with this crazy rash. But, like I also said, I gotta work.” I asked Renaldo what made his pain worse and he said, “Anytime I forget and touch my forehead, it really hurts.” He added, “You know, Doc, the other crazy thing is that if the fan in my room blows on my forehead, I get these sharp pains. What the hell is that about?”

I asked Renaldo to point with one finger to show me where it hurts the most. He pointed to the rash over his left eye, taking care not to touch the area. “Doc, I can’t really point to one place. It kind of hurts all around my left eye and my forehead, and another crazy thing is, sometimes I feel like my hair hurts.” I asked if he had any fever or chills and he shook his head no. I then asked, “What about steroids? Did you ever take any cortisone or drugs like that?” Renaldo again shook his head no. He denied any cancer or human immunodeficiency virus (HIV). Renaldo said, “Doc, you know me, I am happy and healthy,” but with a worried look, he added, “This really has me freaked out. I really need your help!”

On physical examination, Renaldo was afebrile. His respirations were 18 and his pulse was 84 and regular. His blood pressure (BP) was slightly elevated at 144/88. I made a note to recheck it again before he left because he was pretty anxious. He had obvious vesicular lesions over the left eye. He had no lesions in his ear and both his eyes looked normal. His cardiopulmonary examination was unremarkable other than the mild hypertension. His thyroid was normal. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema or adenopathy. His low back examination was unremarkable. I did a rectal exam, which revealed no mass and a normal prostate. The remainder of Renaldo’s physical examination was within normal limits.

Key Clinical Points—What’s Important and What’s Not

What Tests Would You Like to Order?

The following tests were ordered:

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  Complete blood count

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  Chemistry profile

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  Enzyme-linked immunosorbent assay (ELISA) test for HIV