DOCTOR’S NOTES

Personal Details:

Name: Ms. Emily White

Age: 28

Medical Record:

Past medical history: No significant past medical history. Generally fit and well.

Regular medication: None.

Allergies: None known.

Notes:

The last consultation was 1 year ago for a routine contraceptive pill review.

Works as a librarian

PATIENT’S NOTES

Opening Sentence:

“Doctor, I’m here because my fingers and toes keep going really white and numb, especially when I get cold. It’s quite alarming.”

Open History (to give freely):

Ms. White will describe episodes where her fingers (and sometimes toes) turn stark white, then blue, and then red, often accompanied by numbness, tingling, and pain. These episodes are triggered by cold exposure (e.g., going outside in winter, touching cold objects, being in an air-conditioned room) or emotional stress. The colour changes typically last for 10-15 minutes, and the pain is worse as the blood flow returns. She has noticed this happening more frequently over the last few months, especially as the weather has turned colder. She has no other significant symptoms.

ICE:

Ideas: “I looked it up, and it sounds like Raynaud’s phenomenon. I’m just not sure if it’s serious or if it means I have some underlying condition.

Concerns: “I’m worried it might be a sign of something more serious”

Expectation: “I was hoping you could tell me what’s causing it, and if there’s anything I can do to stop it from happening, or at least make it less severe.”

How to Act:

Ms. White should appear concerned but not overly anxious. She should be articulate in describing her symptoms and keen to understand the cause. She should mention her family history and absence of other symptoms if prompted.

More History (only if asked):

The pain can be bad, and in cold weather, it affects both hands and feet, but more in the hands. I’ve had it in previous winters, but it seems much worse this winter.

No skin thickening, joint pain/swelling, muscle weakness, difficulty swallowing, dry eyes/mouth, mouth ulcers, hair loss, rashes, or other systemic symptoms.

Not on any regular or over-the-counter medications (e.g., beta-blockers, triptans, decongestants).

Mum gets something similar, but she’s never been diagnosed with anything specific

Social History:

Occupation: Librarian (spends time in an air-conditioned library).

Smoking: Non-smoker.

Alcohol: Social drinker.

Home situation: Lives with flatmates.

Hobbies/Lifestyle: Enjoys outdoor walks, but finds it difficult in cold weather.

Questions to ask:

Do I need any blood tests?

Is this going to get worse?

What can I do to prevent these attacks?

Could this be something serious?”

EXAMPLE CONSULTATION SCRIPT

Explain the situation, the likely diagnosis or DD, and manage ICE:

·       Thanks for coming in. I understand you’re concerned about your fingers and toes changing colour and feeling numb, especially in the cold. From what you’ve described, it sounds very much like Raynaud’s phenomenon. This is a common condition where the small blood vessels in your fingers and toes go into a temporary spasm in response to cold or stress, reducing blood flow. This causes the colour changes you’ve noticed – white from lack of blood, then blue as oxygen is used up, and finally red as blood flow returns.

·       It’s completely understandable that you’re worried it might be a sign of something more serious. That’s a very sensible concern. However, based on your symptoms – particularly the absence of other issues like joint pain, skin changes, or dry eyes/mouth, and the fact that your mum has something similar – it’s highly likely this is what we call ‘primary Raynaud’s.’ This means it’s not linked to an underlying condition and is generally a benign condition.

Next Steps:

·       The good news is that primary Raynaud’s is usually managed very effectively with lifestyle measures.

·       We can arrange a set of blood tests to check that there are no underlying causes, but just reassure you, I am expecting they all come back normal (FBC, CRP, antinuclear antibody, plasma viscosity).

·       If these measures aren’t enough, or if your symptoms become more severe, we can consider medication such as calcium channel blockers (nifedipine). There are tablets that can help to relax the blood vessels and improve blood flow, but we usually start with non-drug approaches first.

Lifestyle Modifications/self-help measures if relevant:

·       Here are some key things you can do to manage your Raynaud’s:

·       Keep warm: This is the most important thing. Wear warm gloves and socks, even indoors, if you feel cold. Layer your clothing. Consider hand warmers or battery-heated gloves/socks.

·       Protect your core: Keeping your whole body warm helps keep your extremities warm. Wear a hat and scarf when it’s cold.

·       Avoid sudden temperature changes: Try to avoid sudden exposure to cold, like reaching into a freezer without gloves.

·       Exercise: Regular exercise helps improve circulation generally.

·       Medications can worsen Raynaud’s (decongestants, beta-blockers, and migraine medications). Always check with a doctor or pharmacist if you’re prescribed new medication.

·       Regarding your concern about long-term damage, with primary Raynaud’s, it’s very rare to develop complications like ulcers or gangrene. These are more common in secondary Raynaud’s, which is why we’ve gone through your other symptoms carefully. By following these warming measures, you’ll significantly reduce the risk of any issues.

·       I’ll also provide you with some patient information leaflets on Raynaud’s phenomenon, which will cover everything we’ve discussed in more detail. It’s important to be aware of your triggers and take preventative measures. If you develop any new symptoms, like skin changes, joint pain, or if your attacks become much more frequent or severe, please come back and see us. Otherwise, continue with these measures, and you should find your symptoms become much more manageable.

Management objective

What is scenario testing?

·       This scenario primarily tests the GP trainee’s ability to:

·       Differentiate primary from secondary Raynaud’s: Accurately identify the key features that suggest primary Raynaud’s and rule out red flags for secondary causes.

·       Reassure and educate: Provide clear, understandable explanations about the condition and alleviate patient anxiety regarding a serious underlying disease.

·       Provide comprehensive self-management advice: Offer practical, actionable lifestyle modifications and preventative measures.

·       Safety netting: Advise on when to seek further medical attention or if new symptoms develop.

·       Avoid unnecessary investigations: Resist the urge to order blood tests or referrals without a clinical indication.

Important areas in data gathering:

·       Character of attacks: Colour changes (white, blue, red), triggers (cold, stress), duration, pain/numbness.

·       Symmetry and distribution: Affects fingers, toes, nose, ears?

·       Absence of red flag symptoms: No skin changes (sclerodactyly, digital ulcers, pitting scars), joint pain/swelling, muscle weakness, difficulty swallowing, dry eyes/mouth, rashes, hair loss, or other systemic symptoms suggestive of connective tissue disease.

·       Drug history: Medications that can exacerbate Raynaud’s.

·       Family history: Presence of similar symptoms in family members.

·       ICE: Patient’s ideas (Raynaud’s, serious underlying condition), concerns (autoimmune disease, long-term damage), expectations (diagnosis, prevention, treatment).

Highlight the management objectives, i.e. prescribing/referral/reassurance/manage ICE, etc..:

·       Reassurance: Reassure the patient that it is likely primary Raynaud’s and not a serious underlying condition.

·       Manage ICE: Address concerns about autoimmune disease and long-term damage, explaining the benign nature of primary Raynaud’s.

·       Patient education: Provide detailed advice on keeping warm, avoiding triggers, and lifestyle modifications.

·       Safety netting: Explain red flag symptoms that would warrant a return consultation or further investigation.

·       Avoid unnecessary investigations: Do not order blood tests unless there are specific red flags.

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