session 5: rapid fire session: clinical situations presentations...61 y/o woman presents with...

Session 5: Rapid Fire Session: Clinical Situations

Case 1: A 61 Year-old Woman with Painful Blue Finger

Gaurav Parmar, Debbie Hines, Ido WeinbergMassachusetts General Hospital

61 y/o Woman Presents with Painful Blue Finger

61 y/o Woman Presents with Painful Blue Finger- Painful bluish discoloration in the right second digit for 10 days- Describes a burning sensation similar to “touching a hot stove”- The digit: cold, blue, and swollen- she had difficulty making a fist- No arm/hand claudication- PMH: Hypothyroidism- Family history unremarkable- Never smoker- Physical examination: In the right hand, 2nd finger - blotchy patches of

cyanosis, the tip is spared, the finger is tender, the tip is cold, capillary refill is normal, Doppler signals could be obtained, the discoloration does not blanch, and Allen's test is normal

Work-up1. Atherosclerosis – an underlying problem?

• No RFs: Smoking/Hypertension/Diabetes/Dyslipidemia/Family history/Obesity

2. Heart as an Embolic Source?• Echocardiogram: No PFO on bubble studies with valsalva/No intracardiac thrombus/No

atrial myxoma or other cardiac tumors/ No recent MI/Normal LVEF/No MS/No prosthetic valves/No valvular vegetations

• Zio-patch monitoring: No Permanent or Paroxysmal AFib/No sustained Aflutter

3. Hypercoagulability?• Thrombophilia testing: APLA, Protein C/S, ATIII, FVL and Prothrombin 20210 mutations• Normal serum Viscosity and Cryoglobulins

Work-up (cont’d)4. Autoimmune/Rheumatologic/Vasculitis?

• ANA, C3, C4, CRP, ESR, Anti-Scl Ab, and SPEP

5. Anatomical abnormalities?• CTA UE/chest/abdomen – for Dissection/Web/FMD/Extrinsic compression

6. Other causes?• Drugs? No use of cocaine/hormone/anabolic steroids• Buerger disease? No smoking/cannabis use• Cancer? Age-sex appropriate screening normal• Vasospastic disorders? No Raynaud/Migraines

Patient Outcome

Thank you