View source for WBR0182

{{WBRQuestion
|QuestionAuthor=Mugilan Poongkunran
|ExamType=USMLE Step 3
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|Prompt=A 30 year old female a known case of Raynaud’s phenomenon returns to your office and says that treatment is not helping her symptoms and she is experiencing joint pains.  She says that she has been compliant with medications and also have avoided exposure to cold.  She does not smoke or consume alcohol now and even her husband has given up smoking.  Physical examinations are well within normal limits.  Which of the following is the best next step in her line of management?
A.	Increase the dose of medication
B.	Reassure and observe
C.	Add nitroglycerine
D.	Order ANA and RF
E.	Order arterial doppler ultrasonography
|Explanation=The [[Raynaud's phenomenon]] (RP) is considered primary if the symptoms occur alone without any associated disorder.  Secondary Raynaud's phenomenon refers to the presence of the disorder in association with a related illness, such as [[systemic lupus erythematosus]] or [[systemic sclerosis|systemic sclerosis (scleroderma)]].  Patients with primary disease are generally not significantly disabled by the attacks.  By comparison, patients with secondary disease are more likely to have severe attacks, and disease management is more likely to be based upon pharmacologic agents, while continuing nonpharmacologic measures.
|AnswerA=Incorrect
|AnswerAExp=First step is to rule out secondary causes before adjusting the dose in cases who have worsening symptoms while on treatment.
|AnswerB=Incorrect
|AnswerBExp=Patient usually respond to [[calcium channel blockers]].  If they are resistant it requires changes in medication or further investigations.
|AnswerC=Incorrect
|AnswerCExp=In patients who do not respond adequately to a calcium channel blocker (CCB) alone, we suggest the addition of either a phosphodiesterase (PDE) inhibitor (eg, [[sildenafil]]) or another vasodilator.  In patients in whom a phosphodiesterase inhibitor is not available, effective, or well-tolerated, we suggest the use of topical [[nitrates]].
|AnswerD=Correct
|AnswerDExp=Having systemic symptoms and no response to initial treatment warrants investigations like CBC, ANA, RF, serum complements, urine analysis to rule out secondary disease like SLE, scleroderma etc.
|AnswerE=Incorrect
|AnswerEExp=Arterial Doppler is done for patients with digital ulcers.  The treatment of severe refractory Raynaud's phenomenon and ischemic digital ulcers are [[iloprost]] (PGI2 analog), [[epoprosten]] (PGI2 analog) and [[prostaglandin E1]].
|RightAnswer=D
|Approved=Yes
}}