WBR0182

Author	PageAuthor::Mugilan Poongkunran
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Primary Care Office
Sub Category	SubCategory::Musculoskeletal/Rheumatology
Prompt	[[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?]]
Answer A	AnswerA::Increase the dose of medication
Answer A Explanation	AnswerAExp::'''Incorrect''' : First step is to rule out secondary causes before adjusting the dose in cases who have worsening symptoms while on treatment.
Answer B	AnswerB::Reassure and observe
Answer B Explanation	[[AnswerBExp::Incorrect : Patient usually respond to calcium channel blockers. If they are resistant it requires changes in medication or further investigations.]]
Answer C	AnswerC::Add nitroglycerine
Answer C Explanation	[[AnswerCExp::Incorrect : 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.]]
Answer D	AnswerD::Order ANA and RF
Answer D Explanation	[[AnswerDExp::Correct : 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.]]
Answer E	AnswerE::Order arterial doppler ultrasonography
Answer E Explanation	[[AnswerEExp::Incorrect : 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.]]
Right Answer	RightAnswer::D
Explanation	[[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 (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. Educational Objective: References: ]]
Approved	Approved::Yes
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