INSTRUCTION

Examine this patient's hands.

SALIENT FEATURES

History

Ask the patient about the following:· Whether the condition is precipitated by cold, emotion and relieved by heat.· The different phases of Raynaud's phenomenon (in idiopathic Raynaud'sdisease the cold dead-white hands (ischaemia) become blue (stasis) and finally red(reactive hyperaemia) and painful.· Sensory changes secondary to vasospasm (numbness, stiffness, aching pain).· Occupation (polishing tools, vibrating tools).· Dysphagia (CREST syndrome).· Butterfly rash, arthralgia, xerostomia (SLE, collagen vascular disorder).· Use of electrically heated gloves.Examination· Hands may be painful - ask the patient.· The hands and fingers are cyanosed and cold, or may be warm and red or blue. The thumbs are rarely affected.

Proceed as follows:

· Examine the hands carefully for signs of scleroderma (tightening of skin,telangiectasia).· Examine the face for tightening of skin around the mouth (scleroderma), butterflyrash (SLE).· Tell the examiner that you would like to examine upper limb pulses and blood pressure in both upper limbs (useful in the detection of cervical rib)

DIAGNOSIS

This patient has cold, blue hands (lesion) due to Raynaud's phenomenon (aetiology)and is unable to continue her occupation, which requires using a vibratory hand drill(functional status).Read: BMJ 1991; 303: 913; BMJ 1995; 310: 795-8.

ADVANCED-LEVEL QUESTIONS

What are the causes of Raynaud's phenomenon?

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• Immunological and connective tissue disorders

• Scleroderma.· SLE.· Dermatomyositis

• Rheumatoid arthritis

• Mixed connective tissue disorders

• Obliterative arterial disease

• Atherosclerosis

• Thoracic outlet syndrome

• cervical rib

• Occupational

• Vibration

• causing white fingers

• Cold injury, e.g. from handling frozen commodities

• Vinyl chloride.

• Drugs· Beta-blockers.· Bromocriptine.· Sulfasalazine.· Ergot alkaloids.· Combination of bleomycin and vincristine (as for testicular cancer)

• Miscellaneous· Cold agglutinins.· Cryoglobulins.· Idiopathic.Note. Raynaud's disease is diagnosed if the phenomeno

What investigations would you perform to look for autoimmune rheumatic disease in apatient with Raynaud's phenomenon?

FBC, ESR.· Total immunoglobulin and electrophoresis strip.· Urine analysis.· Nail-fold capillaroscopy.· Chest radiography.· Renal and liver function tests.· Test for antinuclear antibody.· H. pylori (one paper suggested that eradication of H. pylori amelioratesRaynaud's phenomenon; Dig Dis Sci 1998; 43: 1641).· Hand radiography.

What drugs have been used to treat Raynaud's syndrome?

Nifedipine, nitrates, stanazolol, inositol nicotinate, naftidrofuryl oxalate, prosta-glandin12, moxisylyte (thymoxamine), guanethidine, prazosin.

What is the role of surgery in treating Raynaud's disease?

Dorsal sympathectomy may be indicated in patients resistant to medical therapy withsevere, frequent attacks, and if trophic changes have occurred, interfering with work.

Do you know of any other vasospastic conditions?

White finger syndrome.· Livedo reticularis.· Erythromelalgia.· Chilblains.Maurice Raynaud (1834-1881) described the sign in 1862. He was a physician atH6pital Lariboisiere, Paris. (Raynaud M (1888) On local and symmetrical gangrene ofthe extremities. In: Barlow T (translator) Selected Monographs, vol. 121. London: NewSydenham Society.)