A 30-year-old woman comes to the physician with the complaint of cold hands. Symptoms occur during winter months or when she reaches into the freezer at home. The coldness is often associated with intense pallor and a bluish color. On recovery, the hands feel warm and appear red and flushed. With severe attacks, the patient has numbness and tingling in the hands. On rare occasions, she can also feel the sensation in her toes. She denies skin rashes, joint pain, acid reflux, dyspnea, or chest pain.
She has no other medical problems and takes no medication. Family history is unremarkable. She does not use tobacco, alcohol, or illicit drugs.
Her blood pressure is 122/70 mm Hg and pulse is 78/min. Lungs are clear on auscultation. No bruits are heard in the periumbilical area. Peripheral pulses are symmetric and full. Skin examination is normal.
Which of the following is the best next step in this patient's evaluation?

Question

A 30-year-old woman comes to the physician with the complaint of cold hands.  Symptoms occur during winter months or when she reaches into the freezer at home.  The coldness is often associated with intense pallor and a bluish color.  On recovery, the hands feel warm and appear red and flushed.  With severe attacks, the patient has numbness and tingling in the hands.  On rare occasions, she can also feel the sensation in her toes.  She denies skin rashes, joint pain, acid reflux, dyspnea, or chest pain.
She has no other medical problems and takes no medication.  Family history is unremarkable.  She does not use tobacco, alcohol, or illicit drugs.
Her blood pressure is 122/70 mm Hg and pulse is 78/min.  Lungs are clear on auscultation.  No bruits are heard in the periumbilical area.  Peripheral pulses are symmetric and full.  Skin examination is normal.
Which of the following is the best next step in this patient's evaluation?

Quizplus · Accepted Answer

11ec193a_992a_cfb4_853d_f59041c09c35_MD0002_00 This patient's presentation suggests primary Raynaud's phenomenon (RP). Patients usually experience biphasic color changes in the digits with thumb sparing during stress or on exposure to cold temperatures. Primary RP usually occurs in healthy women < age 30 without signs of tissue injury or abnormal laboratory findings (eg, ANA and ESR). Secondary RP is usually seen in men > age 40 and presents with signs of tissue ischemia or ulceration, abnormal laboratory findings, and/or systemic symptoms. Thumb involvement is also more common in secondary RP. Nailfold capillary examination can help differentiate between primary and secondary RP. It involves placing oil on the nailfold/cuticle and observing the capillaries with an ophthalmoscope. Normal capillaries are fine loops, and abnormal ones are enlarged with disorganized architecture and microhemorrhages. Normal nailfold capillaroscopy suggests primary RP, which has a low risk for subsequent development of connective tissue disease. Abnormal nailfold capillary structure suggests secondary RP, and the patient should be evaluated for an underlying disorder. (Choice A) Ankle brachial index is performed to diagnose peripheral artery disease in patients with symptoms of claudication. However, this patient has symptoms during cold temperatures rather than with exertion. (Choice B) This patient's absence of focal neurologic symptoms (eg, extremity weakness) makes TIA or stroke unlikely, and carotid duplex ultrasound would not be helpful. (Choice C) This patient has no visual complaints, and dilated funduscopic eye examination would not be helpful. (Choice D) Monofilament testing detects pressure sensation in an extremity and can predict the risk of developing neuropathy, ulcers, or amputation in diabetic patients. Although this patient has hand numbness, the symptoms occur with exposure to cold temperature and are not in the typical stocking-and-glove distribution seen in diabetic neuropathy. Educational objective: Primary Raynaud's phenomenon (RP) usually occurs in women < age 30 with no systemic symptoms, no thumb involvement, normal ANA and ESR tests, and normal nailfold capillaroscopy. Secondary RP is usually seen in men > age 40 with signs of tissue ischemia or ulceration, abnormal laboratory findings and nailfold capillaroscopy tests, and/or presence of systemic symptoms. __________ References: Predictive value of nailfold capillaroscopy in patients with Raynaud's phenomenon. (http://www.ncbi.nlm.nih.gov/pubmed/15951918) Thumb involvement with Raynaud's phenomena as an indicator of underlying connective tissue disease. (http://www.ncbi.nlm.nih.gov/pubmed/20194444)

A 30-Year-Old Woman Comes to the Physician with the Complaint