Case Study of the Week: Raynaud's Phenomenon

Have you ever seen a good case of Raynaud's Phenomenon?  It can be quite impressive.  The first time a patient sees their hands turn cold and blue for no apparent reason, they understandably freak out.  While the symptoms of Raynaud's Phenomenon can be quite alarming, the condition is most often benign.  As a nurse practitioner, it is important you can diagnose and treat Raynaud's, distinguishing it from more dangerous medical conditions. 

Raynaud's phenomenon is simply vasospasm of the fingers and/or toes resulting in decreased blood flow to the hands and/or feet.  The condition can result from cold exposure or stress. Most patients with Raynaud's fall into the category of Primary Raynaud's Phenomenon which is idiopathic and most commonly develops in young women.  Secondary Raynaud's Phenomenon is vasospasm as a result of an underlying illness, usually an autoimmune condition. 

Case Study

A healthy 26 year-old female presents to your clinic with sudden onset of cold, blue hands bilaterally.  She denies pain, numbness and tingling.  She states she has had a similar episode in the past but it was brief and resolved spontaneously.  She denies swelling or injury to the area.  She denies recent illness and does not smoke.  She says she was walking outdoors briefly in cool temperatures but did not consider the cold to be extreme enough to cause the extent of her symptoms. She notes that her fingers briefly turned white before becoming blue in color.  The patient's vital signs are stable, she denies any significant medical history and does not take any medications.

On exam, you note cyanosis to all digits of the patient's upper extremities.  Her fingers are dusky and blue.  Sensation and motor skills remain intact and the patient has good grip strength.  Her pulses are palpable.  Capillary refill to the affected digits is normal.  Color changes are only present in the hands and do not extend beyond the wrist.  Based on this patient's age, history and presentation you suspect her diagnosis is Raynaud's Phenomenon. 

Management and Outcome

There are no definitive imaging studies for diagnosing Raynaud's Phenomenon.  When you suspect a patient has Raynaud's Phenomenon, ruling out potential secondary causes is the first step.  Raynaud's Phenomenon may be medication induced, caused by occupational factors like overuse, or a result of other medical problems such as autoimmune disorders or carpal tunnel syndrome.

Consider ordering lab studies to evaluate for possible renal impairment and dehydration as well as rule out underlying causes.  Other less common labs such as an antinuclear antibody can help further test for contributing factors like autoimmune disorders.  Addressing the underlying medical problem is the treatment for Secondary Raynaud's Phenomenon.

Typically, episodes of Primary Raynaud's Phenomenon resolve spontaneously without complication.  Avoiding environmental factors such as cold help prevent episodes.  Avoiding smoking also helps reduce frequency.  Prescribing vasodilating medications such as calcium channel blockers may help some patients.

Rarely, Raynaud's Phenomenon can cause complications such as ulceration of the digits as a result of reduced blood flow to the area.  Warming, rest, and antiplatelet medications may help in these circumstances.  Very few patients experience complications, for most patients Raynaud's is simply an inconvenience.

Discussion

Although most cases of Raynaud's Phenomenon resolve without complication, nurse practitioners must pay attention to the condition ruling out other potentially dangerous differential diagnoses with similar presentations as well as underlying medical causes.  Reassuring your patients of the condition's benign nature once you have properly diagnosed Raynaud's is also important.  While complications are rare, always discuss concerning signs and symptoms with your Raynaud's patients so they know when to seek further medical assistance. 

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Comments

Why do you neglect to mention the different characteristics of primary and secondary Raynaud's? It seems that most neurologists and physicians fail to diagnose primary or secondary. It could help with very early diagnosis of autoimmune conditions.

Jennifer

I recently diagnosed Reynauds in a women in her areoles and nipples. Very interesting, and she has other autoimmune illnesses. Thanks for the article!

Claire Crunk,WHNP