Mr. A is a 35-year-old male who presents with episodic discoloration of his left middle finger from white to red upon cold exposure. Examination was unremarkable. He likely has primary Raynaud's phenomenon given his symptoms and negative workup. Treatment includes lifestyle modifications and medication like nifedipine to avoid vasoconstriction.

1. Morning Report
Presenter : Dr.Abdullah Almazyad R1
Moderator : Dr.Saud Alsaloom R3

2. Chief Complain
• Mr.A is a 35 years old male presented to
Rheumatology Clinic complaining of episodic
Discoloration of his left middle finger (White
Red)
• Questions ?

3. History of Presenting Illness
• Mr.A Is 35 yo medically free presented to clinic complaining of discoloration of his left
middle finger upon exposure to cold weather or surfaces , it started as white then red without
a change to blue colour , there was no pain during episodes , and usually improves on warm
up , each episode last less then 5 mintues and involve the whole finger but spares the hand ,
patient visited multiple private clinics with no clear diagnosis , and received HCQ for a month
1 year ago
• Pt also gave history regarding bilateral joint pain of the DIP and PIP in 2nd and 3rd fingers of
the hand , this pain is mild 3-4 out of 10 on and off , associated with morning stiffness less
then 25 minutes , pain has started since 3 years ago with similar severity throughout the
course , pain doesn't improve with activity , responds mildly to NSAIDs
• No hx of oral or genatalial ulcer , rash , alopecia , change in vision acuity or blurry vision ,
no evidence of vasculitis , no hemoptysis , no hx of recurrent infarction , no abdominal pain ,
no hematuria , no history of recurrent headaches or change in mental status

5. • Past Medical and surgical :
– No Hx of Chronic Illness
– No Hx of Major Surgeries or Car Accidents
– No Hx of blood Transfusion or Allergy
– He only received HCQ for a month 1 year ago , otherwise the only medications he is using are
Over-the-Counter Analgesics
• Family Hx :
– His Mother was diagnosed with RA controlled on MTX and HCQ , and DM
– His Father was diagnosed with HTN and DM
– He has 4 brothers and 4 sisters , all of them are medically free
– No Family Hx of similar Episodes in the family
• Social Hx :
– he lives in a town nearby Riyadh
– He works as a teacher in a highschool
– He Smoked for for 8 years 1-2 packs per year , Ex-Smoker for last 9 years
– He doesn’t exercise regularly however he follows a Carb Free diet

6. Review of Systems
• Respiratory :
– No chough , no SOB , no hemoptysis
• Gastrointestinal :
– No abdominal pain , no dysphagia , no diarrhea
• Genitourinary :
– No dysuria , no flank pain , No Hesitancy
• Neurological :
– No weakness , no dizziness , No Headache
• Musculoskeletal :
– Mild Joint Pain in DIPs and PIPs of both hands , Morning Stiffness < 25, no history of
Trauma
• Hematology :
– No Bruising , no history of ease of bleeding, no history of Autoimmune disease
• Endocrine :
– No history of cold intolerance or Polyuria

7. General Examination :
Patient was setting on a chair comfortably , with no IV line or a monitor connected
to him , he looks well with acceptable body weight
Hand Examination :
-there was no rashes , ulcers , or discolorations
-no joint pain , redness , tenderness , swelling , or change in temperature
-no limitation in range of motion
Head and Neck :
-no Malar rash , no Jaundice , no Alopecia , no evidence of Annuler stomatitis , no
Cyanosis
- JVP wasn’t raised
- No Generalized Lymphadenopathy

8. CardioVasculer Exam
• Reguler pulse with rate of 78
• Inspection : no visible prominent veins , no visible pulsation , no
Scars , No discoloration , JVP wasn’t raised
• Palpation : no palpable thrills or Parasternal heaves , PMI was in
midclavicular line 5th intercostal space , No tenderness
• Auscultation : First and Second Heart sounds are audiable in all
auscultatory areas with no added sounds , no Murmurs
• No Basal Crackles , No lower limbs edema , no splenomegaly

9. Respirstory Examination
• Inspection :
– Chest movement was symmetrical , RR : 18
• Palpation :
– Trachea was central ,equal chest expansion , no Subcutaneous
emphysema
– No palpable lymph nodes (anterior and posterior triangle ,
Supraclavicular , and axillary region)
• Percussion :
– Bilateral Resonant all over chest
• Auscultation :
– Vesicular Breathing equal bilaterally all over chest
– No Wheezing or crackles

10. Gastrointestinal Examination
• Inspection :
– Normal Abdominal Contour , symmetrical , Umbilicus is inverted
– No visible hernia , no visible dilated veins , no visible masses
• Palpation :
– Soft and lax , no tenderness , no palpable masses
– No Hepatomegaly or Splenomegaly
• Percussion :
– No shifting dullness
– Liver span is approximately 10 cm
• Auscultation :
– Audible bowel sounds , no renal bruit

11. Musculoskeletal Examination
• Joints :
– No visible joint or bone deformities
– No tenderness on movement or palpation , no swelling
, no difference in temperature
– No decreased ROM , swelling or erythema
• Muscle :
• No Proximal or Distal Weakness , no Tenderness

12. Neurological Examination
• GCS : 15/15
• Upper limbs :
– Sensory : intact for touch and pain
– Normal power , tone and reflexes
• Lower Limbs :
– Sensory : intact to touch and pian
– Normal power , tone and reflexes

13. Summary
• Mr.A Is 35 yo medically free presented to clinic
complaining of discoloration of his left middle
finger upon exposure to cold weather or surfaces ,
no pain during episodes , and usually improves on
warm up
• Examination was unremarkable

14. DDx?

15. Labs :
• CBC :

16. Electrolyte and Renal Profile

17. • Beta 2 Glycoprotien IgG : <9 (N)
• Beta 2 Glycoprotien IgM : 3.7 (N)
• ANCA : MPO :0.9 (N) PR3 : 1.5 (N)
• ANA Secreen : Negative
• ACA : IgG4.5 (N) IgM:4.2 (N)
• Lupus Anticoagulent : Negative
• Cryglobulin : Negative
• C3 : 0.98 (N) C4:0.4 (N)
• Anti-CCP : 1.5 (N)
• Rheumatoidal Factor : 9.38 (N)
• ESR : 11 (N)
• CRP : 0.3 (Low)

18. Bilateral Hand X-Ray

19. Plan :
• Non-Pharmacological approach :
– Avoid Cold surfaces and cold weather
– Use gloves when exposure is necessary
– Apply Warm once discoloration develops
– Nifedipine 90 mg PO
• Bilateral Hand X-Ray to look for Osteoarthritis

20. Raynaud Phenomenon
• Primary Raynaud Phenomenon :
– Idiopathic , not associated with any rheumatological disease ,
usually happens in young female
• Secondary Raynaud Phenomenon :
– Typically more sever , associated with other connective tissue
disorder mostly Scleroderma and frequently in RA and SLE
• Medications that can exacerbate Raynaud’s :
– -Seratonin Agonists (Triptans , BB )
– -Chemotheraputic Agents (Bleomycin and Vinblastin)
– -Sympathomimetics (Decongestants , Clonidine , and Cocaine)

21. • Raynaud's Discoloration : White  Blue  Red as a result of vasoconstriction
upon exposure to cold or Emotional stress
• But it can happen with only White  Red in some pts
• Fingertip Ulceration is an indicator of underlying rheumatological disease
• Do Nailfold Capillaroscopy : shows abnormal , dialated , tortous Capillaries at the
nail bed
• Tx :
• Avoiding Cold , drugs that causes vasoconstriction , smoking
• CCB and Nitroglycerine transdermal patch
• Digital Sympathectomy for whom faild medical Tx and who continue to
experience ischemia

24. DDx of Raynaud’s Phenomenon
• Subclavian Steal Syndrome
• Thromboangiitis obliterans
• Erythromelagia
• Acrocyanosis
• Chillblains

25. Subclavian Steal Syndrome SSS
• retrograde (reversed) blood flow in the vertebral artery or the internal
thoracic artery, due to a proximal stenosis (narrowing) and/or occlusion of
the subclavian artery
• Sx : Syncope and Presyncope , Neurological Deficit , BP Deffirance
between the two arms , Discoloration of the Hands with Ulcers
• Atheroscelarosis is the most common cause , also could be Iatrogenic with
Repair of Coarctation of Aorta , or as a complication of certain diseases
like Takayasu Arteritis leading to a dense scar tissue
• Dx with Ultrasound and CT angiography
• Tx : with Carotid Subclavian Bypass or Stent and angioplasty

26. Thromboangiitis obliterans
• Recurring progressive infilmation and thrombosis (clotting) of small and
medium arteries and viens of the hands and feet , Hugely associated with
Smoking
• Sx : Pain and claudication in the affected area , Discoloration of the tips of
fingers and toes (it ranges from Cyanotic blue to Reddish blue) ,
Peripheral pulses are diminished
• Diagnosed with the following criteria :
1. Typically between 20–40 years old and male, although recently females have been diagnosed.
2. Current (or recent) history of tobacco use.
3. Presence of distal extremity ischemia (indicated by claudication, pain at rest, ischemic ulcers or gangrene) documented by
noninvasive vascular testing such as ultrasound.
4. Exclusion of other autoimmune diseases, hypercoagulable states, and diabetes mellitus by laboratory tests.
5. Exclusion of a proximal source of emboli by echocardiography and arteriography.
6. Consistent arteriographic findings in the clinically involved and noninvolved limbs
Tx : Smoking cessation and Symptoms tx with Prosstaglandins , Bypass can
be helpful

27. Erythromelagia
• Is a vascular peripheral pain disorder in which blood vessels,
usually in the lower extremities or hands, are episodically
blocked (frequently on and off daily), then
become hyperemic and inflamed
• Sx : on and off , sever burning pain , skin redness , attacks
exacerbated by heat , pressure or mild exertion
• Diagnosis : No specific Test available
• Secondary treated by treating underlying causes , Primary is
treated with symptomatic management

28. Acrocyanosis
• persistent blue or cyanotic discoloration of the extremities
• Sx : Persistent cyanotic discoloration , Cold and Clammy ,
sweating with various ranges
• Usually diagnosed Clinically based on history and clinical
exam
• There is no standard medical or surgical treatment for
acrocyanosis, and treatment, other than reassurance and
avoidance of cold, is usually unnecessary