A 33-year-old Caucasian female presents to your office with a six-month history of cold intolerance. When the weather is cold, her third and fourth fingers on both hands get numb and turn blue. She says, 'I wear gloves to keep my hands warm, but it does not always work'. Her past medical history is significant for non-ulcer dyspepsia treated with omeprazole. She does not smoke or consume alcohol, and denies any recreational drug use. She has no known drug allergies. She works as a nurse at a local hospital and considers her job moderately stressful. She is sexually active with her husband and uses condoms for contraception. Physical examination findings are within normal limits.
The patient returns in one month and complains that the treatment 'does not help much.' In addition, she has started to experience periodic joint and muscle pain. She says that she has been adherent to the medication and has tried to avoid going out in cold weather as much as possible. Her husband even gave up smoking because you had warned her that passive smoking may worsen her condition. Which of the following is the best next step in the management of this patient?

Question

A 33-year-old Caucasian female presents to your office with a six-month history of cold intolerance.  When the weather is cold, her third and fourth fingers on both hands get numb and turn blue.  She says, 'I wear gloves to keep my hands warm, but it does not always work'.  Her past medical history is significant for non-ulcer dyspepsia treated with omeprazole.  She does not smoke or consume alcohol, and denies any recreational drug use.  She has no known drug allergies.  She works as a nurse at a local hospital and considers her job moderately stressful.  She is sexually active with her husband and uses condoms for contraception.  Physical examination findings are within normal limits.
The patient returns in one month and complains that the treatment 'does not help much.'  In addition, she has started to experience periodic joint and muscle pain.  She says that she has been adherent to the medication and has tried to avoid going out in cold weather as much as possible.  Her husband even gave up smoking because you had warned her that passive smoking may worsen her condition.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: Raynaud phenomenon may be idiopathic (also called Raynaud disease) or secondary to other conditions such as connective tissue diseases, vascular lesions, medications, etc. When managing patients with Raynaud phenomenon, potential precipitating factors such as medications and environmental factors (e.g., frostbite, vibration) should first be excluded. The presence of symptoms suggestive of systemic disease (arthralgias and myalgias) and resistance to treatment (such as in this patient) warrant further evaluation; this may include ANA, RF, CBC, blood chemistry, urinalysis and measurement of complement levels. (Choice E) Patients are diagnosed with primary Raynaud phenomenon when there are no historic clues to a secondary condition, normal physical findings and no ischemic digital lesions. No specialized studies are indicated in these patients. (Choice C)In patients who have symptoms suggestive of vascular lesions (e.g., asymmetric involvement and deficient pulses), further evaluation with digital plethysmography, arterial Doppler ultrasonography or angiography should be considered. (Choices A and B) It is not reasonable to change the treatment without first excluding a systemic disease that may be responsible for the condition. Educational Objective: The presence of symptoms suggestive of systemic disease (arthralgias, myalgias, fever, and weight loss) in patients with Raynaud phenomenon warrants further evaluation; this may include ANA, RF, CBC, blood chemistry, urinalysis and measurement of complement levels.

A 33-Year-Old Caucasian Female Presents to Your Office with a Six-Month History