How to write a case summary for Raynaud's phenomenon

A good rheumatology summary is short (6 to 10 lines) and does three things. It states the one-line problem. It shows the reasoning for primary versus secondary Raynaud's. It gives a clear plan.

Structure

1. One-line identifier Age, sex, key comorbidities, presenting complaint and duration.

2. History of presenting illness

Attack features: triphasic colour change (white, then blue, then red), triggers (cold, stress), duration, frequency, which digits, and whether the thumbs are spared.
Severity: pain, digital ulcers, pitting scars, gangrene.
Onset age and course: onset after age 40 and progressively worsening attacks predict a connective tissue disease. Goldman-Cecil and Andrews cite one cohort of 3035 patients in which 37.2% were reclassified as secondary after about 4.8 years (Andrews' Diseases of the Skin, Raynaud Phenomenon and Raynaud Disease).
Associated symptoms:
- Skin and hands: puffy or swollen fingers, skin tightening, telangiectasia, calcinosis.
- Joints and muscle: joint pain, morning stiffness, proximal weakness.
- Sicca, photosensitivity, oral ulcers, rash.
- GI: reflux, dysphagia.
- Lungs and heart: dyspnoea, cough.
Mimics and causes to ask about: smoking, hand-arm vibration or occupational exposure, family history (30 to 50% of primary cases have an affected first-degree relative).
Drugs: beta-blockers, clonidine, ergots, amphetamines or ADHD stimulants, cocaine, oral contraceptives, cyclosporine, chemotherapy (Goldman-Cecil Medicine, Table 66-4).

3. Examination (pertinent positives and negatives)

Vitals and peripheral pulses: include the Allen test and BP in both arms.
Fingers: skin thickening (sclerodactyly), puffy fingers, digital pitting scars or ulcers, telangiectasia, calcinosis, and the nailfold (dilated loops, haemorrhages, drop-out).
Other signs: rash, synovitis, proximal muscle strength, and a chest and cardiac exam.

4. Investigations

Nailfold capillaroscopy: normal findings favour primary Raynaud's. An abnormal scleroderma pattern predicts systemic sclerosis (Andrews').
Autoantibodies: ANA, plus ENA, anti-centromere, anti-Scl-70 and anti-RNA polymerase III if ANA is positive.
Baseline blood tests: CBC, ESR/CRP, creatinine, urinalysis, TSH, and CK if myositis is suspected.
Targeted tests: cryoglobulins, SPEP, and hepatitis serology if indicated.
Organ screening if secondary: HRCT or PFTs, and echo for PAH.

5. Assessment State the classification and your reasoning in one or two lines. For example: "Likely secondary Raynaud's (early SSc spectrum) given age of onset over 40, puffy fingers, positive ANA with anti-centromere, and abnormal nailfold capillaries." Then add the severity and complications, such as digital ulcers or critical ischaemia.

6. Plan

All patients: education, cold avoidance, hand warmers or gloves, smoking cessation, and stopping culprit drugs.
First-line drug: a calcium channel blocker such as nifedipine.
Next steps if the first drug fails: PDE-5 inhibitors, topical nitrates, or an ARB or fluoxetine.
Severe or ulcerating disease:
- IV prostanoids (iloprost).
- Bosentan to prevent new digital ulcers in SSc.
- Urgent referral for critical ischaemia.
Follow-up: repeat antibodies and capillaroscopy if the initial work-up was negative.

Drug choices above come from my own knowledge, not from the textbook passages I read. Check them against local guidelines.

Primary versus secondary: quick reasoning table

Feature	Primary	Secondary
Onset age	Usually under 30	Often over 40
Severity	Mild, symmetric	Severe, may be asymmetric
Ulcers or gangrene	Absent	Possible
Nailfold capillaries	Normal	Abnormal
ANA / specific antibodies	Negative	Often positive
Systemic features	None	Present (SSc, SLE, MCTD, Sjögren's, myositis)

The textbook notes that normal nailfold findings predict primary Raynaud's. Positive ANA, finger thickening, older onset and female sex predict progression to connective tissue disease (Andrews', Raynaud Phenomenon and Raynaud Disease).

Sample summary

38-year-old woman, non-smoker, with a 6-month history of cold-induced triphasic colour change in the fingers (thumbs spared), now with two episodes of fingertip ulceration. She reports puffy fingers and reflux but no dyspnoea, rash or joint pain, and takes no vasoconstrictive drugs. On exam she has puffy fingers, digital pitting scars and telangiectasia, with normal pulses and no synovitis. ANA is positive 1:640 (centromere pattern), and nailfold capillaroscopy shows dilated loops with drop-out. Assessment: secondary Raynaud's phenomenon, most likely limited cutaneous systemic sclerosis, complicated by digital ulcers. Plan: nifedipine, cold protection, ulcer care, HRCT and PFTs, echocardiogram for PAH screening, and rheumatology follow-up in 4 to 6 weeks.

Sources and evidence check

Goldman-Cecil Medicine, Raynaud Phenomenon, for definition, prevalence and Table 66-4.
Andrews' Diseases of the Skin, Raynaud Phenomenon and Raynaud Disease, for progression and capillaroscopy.
A PubMed search for systematic reviews and meta-analyses from the past 2 years found nothing that contradicts this approach. The three hits were about ADHD-drug-associated Raynaud's, the nipple, and primary biliary cholangitis.

If you tell me whether this is for an exam long case, a ward presentation or a discharge summary, I can reformat it to match.

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