A 51-year-old woman comes to the office due to 2 months of pain and numbness of her right index and middle fingers. Her fingers turn white when subjected to cold, and they hurt until she thoroughly warms them. The patient has no problems with her left fingers or toes. Medical history is significant for chronic cough, lower back pain, and acid reflux disease. She has a 28-pack-year smoking history. On examination, there are 2 small ulcers on the tip of her right index finger. Which of the following is the best next step in management of this patient?

Question

A 51-year-old woman comes to the office due to 2 months of pain and numbness of her right index and middle fingers.  Her fingers turn white when subjected to cold, and they hurt until she thoroughly warms them.  The patient has no problems with her left fingers or toes.  Medical history is significant for chronic cough, lower back pain, and acid reflux disease.  She has a 28-pack-year smoking history.  On examination, there are 2 small ulcers on the tip of her right index finger.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d519_afb0_bc81_edb57e2d0d5a_MD0003_00 This patient's clinical features suggest Raynaud phenomenon (RP), which is caused by abnormal vasoconstriction of digital arteries in response to cold or emotional distress. Primary RP is not associated with a systemic disorder, but secondary RP (eg, systemic lupus erythematosus, scleroderma, thromboangiitis obliterans) is. Patients typically experience sudden onset of cold at the extremities (fingers or toes) and sharply demarcated color changes (white or blue) of the digits. Primary RP typically affects young patients (ages 15-30, often female), who have symmetric episodic attacks without tissue injury. Patients with secondary RP are generally older (age >40, often male) and have asymmetric attacks with clinical features of tissue ischemia (eg, numbness, ulcers) and systemic disease (autoimmune or vascular). Based on history and physical examination, workup for patients with suspected secondary RP may include: Complete blood count and metabolic panel Urinalysis Antinuclear antibody (ANA) and rheumatoid factor Erythrocyte sedimentation rate and complement levels (C3 and C4) If the ANA screen is positive, specific antibodies (eg, antitopoisomerase-1 for systemic sclerosis) may be obtained. (Choice B) An arteriogram may be used to diagnose thromboangiitis obliterans (Buerger disease), a vasculitis that affects small and medium-sized arteries of young patients who smoke. It presents with distal-extremity ischemia, ulcers, or gangrene. Thromboangiitis obliterans is more common in men, typically presents age 40-45, and is usually diagnosed after the exclusion of other systemic diseases (eg, diabetes mellitus, autoimmune and hypercoagulable disorders); therefore, ANA and other blood tests should be obtained prior to an arteriogram (a more invasive study) in this patient. (Choice C) Treatment of RP includes smoking cessation and avoidance of cold temperatures and emotional stress. Pharmacologic therapy includes dihydropyridine calcium channel blockers (CCB) such as nifedipine or amlodipine. Some studies have shown limited benefit of losartan in decreasing RP attacks in patients unable to tolerate CCB (or other recommended agents). (Choice D) Although hypothyroidism can cause cold vasospasm, it generally does not cause tissue ischemia or well-demarcated digit color changes. (Choice E) Transthoracic echocardiogram is useful for initial evaluation of infective endocarditis (IE). This patient's skin manifestations are not suggestive of Janeway lesions (ie, painless, erythematous lesions on palms or soles) or Osler nodes (ie, painful, papular pustules on pulp of fingers or toes) typically found in patients with bacteremia and IE. Educational objective: Raynaud phenomenon (RP) is abnormal vasoconstriction of digital arteries in response to cold or emotional stress. It may be primary, or may occur in association with systemic disease, especially autoimmune disorders. Patients with suspected secondary RP should be tested for autoantibodies and inflammatory markers. References: Raynaud's phenomenon. (http://www.ncbi.nlm.nih.gov/pubmed/21117349)

A 51-Year-Old Woman Comes to the Office Due to 2