Information Sheet for Candidates

A 45 year old waiter, John, comes to you for a flu

injection and he mentions that he has increasing
difficulties with his job, carrying heavy trays. The
fingers in his right hand have become numb and
painful on a couple of occasions and he wonders if
there is any treatment to prevent this happening.

YOUR TASKS ARE TO:

1. Take a focused history and perform an
examination
2. Explain the most likely diagnosis, the underlying
pathology and the treatment to
the patient.
 HISTORY:

Over the last 4 weeks John noticed a couple of occasions where the fingers in his right
hand suddenly became quite pale, painful and numb.
Actually after a while they spontaneously recover and they then become first blue and
then quite dark red before taking on their normal colour and function again.

P.Hx.:
John has never been sick or in hospital.

SHx.: married, no children, has been a waiter for 35 years, smokes about 30 cigarettes
per day, drinks about 6 beers every night.
No medication, no allergy

FHx.: John does not know his parents, was orphaned at very young age.

EXAMINATION: (LOOK, LISTEN, FEEL !!!!):

At present totally unremarkable examination.

??? Cold water challenge to confirm it???!!!

DIAGNOSIS: RAYNAUD’S PHENOMENON (VASOSPASTIC DISEASE)

It mainly affects the small digital arteries and arterioles of the upper and lower
extremities. Common symptoms include pain, numbness, coldness, and occasionally, skin
ulcers. Vasospasm may be associated with collagen vascular disease, atherosclerosis,
trauma and embolism from peripheral arterial lesions. Although often no cause is
identifiable.
Typical symptoms are (triphasic):
1. PALLOR due to severe vasospasm
2. CYANOSIS due to sluggish blood flow and resultant marked blood
desaturation
3. RUBOR due to the reactive hyperaemia

MANAGEMENT:
1. Avoid cold environment
2. avoid smoking
3. Ca-channel blockers like nifedipine can help,
phenoxybenzamine (dibenyline), a peripheral vasodilator could
be tried.