Diagnosis of Raynaud's phenomenon
Diagnostic Test list for Raynaud's phenomenon:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Raynaud's phenomenon
includes:
Raynaud's phenomenon Diagnosis: Book Excerpts
Tests and diagnosis discussion for Raynaud's phenomenon:
Questions and Answers about Raynaud's Phenomenon: NIAMS (Excerpt)
If a doctor suspects Raynaud's phenomenon, he or she will
ask the patient for a detailed medical history. The doctor will then
examine the patient to rule out other medical problems. The patient
might have a vasospastic attack during the office visit, which makes it
easier for the doctor to diagnose Raynaud's phenomenon. Most doctors
find it fairly easy to diagnose Raynaud's phenomenon but more difficult
to identify the form of the disorder. (See the
box for the criteria doctors use to diagnose primary or secondary
Raynaud's phenomenon.)
Nailfold capillaroscopy (study of capillaries under a
microscope) can help the doctor distinguish between primary and
secondary Raynaud's phenomenon. During this test, the doctor puts a drop
of oil on the patient's nailfolds, the skin at the base of the
fingernail. The doctor then examines the nailfolds under a microscope to
look for abnormalities of the tiny blood vessels called capillaries. If
the capillaries are enlarged or deformed, the patient may have a
connective tissue disease.
The doctor may also order two particular blood tests, an
antinuclear antibody test (ANA) and an erythrocyte sedimentation rate
(ESR). The ANA test determines whether the body is producing special
proteins (antibodies) often found in people who have connective tissue
diseases or other autoimmune disorders. The ESR test is a measure of
inflammation in the body and tests how fast red blood cells settle out
of unclotted blood. Inflammation in the body causes an elevated
ESR.
Diagnostic Criteria for Raynaud's
Phenomenon
Primary Raynaud's Phenomenon
- Periodic vasospastic attacks of pallor or cyanosis (some
doctors include the additional criterion of the presence of
these attacks for at least 2 years)
- Normal nailfold capillary pattern
- Negative antinuclear antibody test
- Normal erythrocyte sedimentation rate
- Absence of pitting scars or ulcers of the skin, or gangrene
(tissue death) in the fingers or toes
Secondary Raynaud's Phenomenon
- Periodic vasospastic attacks of pallor and cyanosis
- Abnormal nailfold capillary pattern
- Positive antinuclear antibody test
- Abnormal erythrocyte sedimentation rate
- Presence of pitting scars or ulcers of the skin, or gangrene
in the fingers or toes
|
(Source: excerpt from
Questions and Answers about Raynaud's Phenomenon: NIAMS)
NHLBI, Raynaud's Phenomenon: NHLBI (Excerpt)
An attack
is usually temporary, so the doctor relies on the patient's description to
diagnose the problem. The doctor will also determine whether the patient has
Raynaud's alone (called primary Raynaud's phenomenon) or if another disease or
some aspect of the patient's lifestyle is causing the symptoms. If the problem
is caused by another disease or risk factor, the patient is said to have
secondary Raynaud's phenomenon.
(Source: excerpt from NHLBI, Raynaud's Phenomenon: NHLBI)
Diagnostic Tests for Raynaud's phenomenon: Online Medical Books
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Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Raynaud's phenomenon.
RAYNAUD'S PHENOMENA:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there a history of drug ingestion? Ergotamine, methysergide, and beta-adrenergic receptor blockers are just a few of the drugs that may cause Raynaud's phenomena.
- Is there involvement of only one upper extremity? When there is involvement of only one upper extremity, thoracic outlet syndrome, especially cervical rib, arteriosclerosis of the subclavian artery, and embolism should be considered.
- Is there thickening of the skin? Thickening of the skin should bring to mind scleroderma.
- Is there hypertension? The presence of hypertension might suggest periarteritis nodosa and other collagen diseases, polycythemia vera, macroglobulinemia, cold agglutinins, and sickle cell anemia.
- Are there abnormalities of the blood cells, red cell mass, or serum proteins? These findings would suggest polycythemia vera, macroglobulinemia, cold agglutinins, and sickle cell anemia.
DIAGNOSTIC WORKUP
Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, serum protein electrophoresis, ANA titer, chest x-ray, and EKG.
If macroglobulinemia is suspected, a Sia water test and serum immunoelectrophoresis may be done. If cold agglutinins are suspected, a test for cold agglutinins may be done. A sickle cell preparation may be necessary if the patient is black. Collagen diseases may be further evaluated by skin and muscle biopsy and esophageal manometry.
Raynaud's phenomena may be demonstrated by immersing the hands in water at a temperature of 10° to 15°C. Whole body exposure to cold is an even better way of demonstrating the actual Raynaud's phenomena. The finding of nail-fold capillary-loop dilation and drop out may also help diagnose Raynaud's phenomena. If scleroderma is suspected, an antisclerodermal antibody titer is done.
Doppler studies and arteriography will rule out subclavian artery occlusions. A rheumatology or neurology consultation may be helpful.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Raynaud's Phenomenon:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Primary (idiopathic) disease
-
Secondary disease associated with underlying systemic conditions
–Scleroderma or CREST
–Systemic lupus erythematosus
–Rheumatoid arthritis
–Mixed connective tissue disease
–Sjögren's syndrome
-
Arteriosclerosis obliterans
-
Thromboangiitis obliterans
–Associated with male smokers
-
Arterial embolism
–Acute onset
–Pulseless
-
Cryoglobulinemia
–Hepatitis C
-
Cold agglutinins
–Mycoplasma infection
-
Macroglobulinemia
–Multiple myeloma
-
Polycythemia vera
-
Vasculitis (e.g., Wegener's granulomatosis)
-
Hepatitis B
-
Hypothyroidism
-
Thoracic outlet syndrome (brachial plexus)
-
Carpal tunnel syndrome
-
Drugs: β-blockers, methysergide, bleomycin, vinblastine, clonidine, cyclosporine, ergot preparations
-
Trauma
–Often associated with vibratory tool workers, pianists, typists, or meat cutters
-
Hypothenar hammer syndrome
-
Reflex sympathetic dystrophy
-
Multiple sclerosis
-
Syringomyelia
-
Poliomyelitis
-
Neoplasms
-
Vinyl chloride poisoning
-
Arteriovenous fistula
Workup and Diagnosis
-
Thorough history and physical examination
-
CBC with differential may identify various cytopenias associated with connective tissue diseases
-
TSH to rule out hypothyroidism
-
Hepatitis serologies
-
Creatine phosphokinase to rule out polymyositis
-
Complement levels are low in SLE
-
ANA, ESR, and rheumatoid factor to screen for collagen vascular diseases
-
Directed autoantibody testing according to presentation
–Anti-double stranded DNA and anti-Sm (SLE)
–Anti-SSA (Sjögren's syndrome)
–Anti-centromere (CREST syndrome)
–Anti-ribonucleoprotein (mixed connective tissue disease)
–Anti-Scl 70 (scleroderma)
–ANCA (Wegener's granulomatosis)
-
Serum cryoglobulins and cold agglutinins
-
Serum protein electropheresis to rule out paraproteinemia
-
EMG/nerve conduction studies to rule out brachial plexus pathology and carpal tunnel syndrome
-
Age-appropriate cancer screening
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Raynaud Phenomenon:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Raynaud phenomenon is triphasic
–Pallor (white): Decreased cutaneous blood flow
–Cyanosis (blue): Venous stasis
–Erythema (red): Reflex vasodilation
–Fingers are affected more than toes; earlobes, tip of nose, lips, and tongue may also be affected
–The presence of intense, painful episodes with ischemic skin lesions and clinical features (arthritis, rash) of a connective tissue disease suggests a secondary cause
–Idiopathic Raynaud is uncommon in children apart from familial benign type; however, if there are no clinical or laboratory signs in the 2 years after Raynaud develops, an underlying disease is unlikely
-
Familial benign type
–Median age at onset is around 14 years
–Positive family history in a first-degree relative in 25%
–ESR is normal and ANA is negative
-
Connective tissue disease
–Scleroderma: Almost 90% have Raynaud; it is the initial symptom in most cases
–May also be found in SLE and CREST syndrome
-
Vascular diseases
–Takayasu arteritis
–Giant cell arteritis
–Arteriosclerosis
–Thromboangitis obliterans
–Thoracic outlet syndrome
-
Environmental causes
–Frostbite
–Polyvinyl chloride disease
–Vibration disease
–Hypothenar hammer syndrome
-
Neuropathy (e.g., carpal tunnel syndrome)
-
Primary endocrine abnormalities
–Hypothyroidism
–GH excess/acromegaly
-
Hormone-secreting tumors
–Pheochromocytoma
–Carcinoid syndrome
Workup and Diagnosis
- History
–Sensitivity to cold with color changes (white or blue)
–Medication and environmental/cold injury, toxins, digital ulcers, long-lasting wounds
–Signs and symptoms of a possible systemic disease (myalgias, arthralgias/arthritis, weakness, weight loss, fever, rash; respiratory, CV, and GI symptoms)
-
Physical exam
–Vital signs (fever, tachypnea, tachycardia, absent pulses, asymmetric blood pressure)
–Skin exam for rashes and ulcers
–Nail fold capillary exam
–Arthritis
–Lymphadenopathy
–Organomegaly
-
Labs
–Indicated for patients with signs and symptoms
compatible with a systemic disease
–CBC with differential, ESR/CRP, chemistry, urinalysis
–ANA and disease-specific autoantibodies, C3, C4
–TFTs, serum protein electrophoresis, cryoglobulins
- Vascular studies
–Indicated for patients with history of asymmetric attacks, physical exam findings of absent pulses, blood pressure asymmetry, evidence of ischemia
–Doppler ultrasonography
–Plethysmography
–Angiography
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Raynaud's disease:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Clinical criteria that establish Raynaud’s disease include skin color changes induced by cold or stress; bilateral involvement; absence of gangrene or, if present, minimal cutaneous gangrene; normal arterial pulses; and patient history of clinical symptoms of longer than 2 years’duration. Diagnosis must also rule out secondary disease processes, such as chronic arterial occlusive or connective tissue disease.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Raynaud's Phenomenon:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Description of attack. What is the sequence of color changes, including their location, frequency, and duration? Are there associated symptoms?
1. The classic sequence of events is a symmetric, white, blanching, sharply demarcated discoloration, followed by cyanosis, and then redness with resolution of the attack after approximately 15 minutes. Two colors, most commonly white and blue, are sufficient for a firm diagnosis. The presence of only one color makes the diagnosis tenuous.
2. Fingers are usually involved, whereas the thumb and toes are less commonly affected. Rarely, the earlobes, nose, and lips are involved.
3. Associated symptoms can include clumsiness, paresthesias, or pain.
4. Symmetric, mild attacks without tissue loss are typical of primary RP.
5. Asymmetric, prolonged, or intensely painful attacks associated with tissue injury are characteristic of secondary RP.
B. Triggers
1. Cold exposure is by far the most common trigger.
2. Other triggers include emotional stress and nicotine.
C. Underlying illnesses or causes. Are there symptoms or a known underlying disease that suggest secondary RP is present? The most common disorders are connective tissue diseases, especially systemic sclerosis or CREST syndrome; atherosclerotic disease; hyperviscosity syndromes; occupational exposure to intense vibration or vinyl choloride; and medications such as beta- blockers, clonidine, ergot drugs, and some chemotherapeutic agents (vinblastine, bleomycin, and cisplatin).
D. Other information. Does the patient take unopposed estrogen or have a history or migraine headaches, chest pain, or possible Helicobacter pylori infection?
1. Unopposed estrogen therapy or the presence of H. pylori infection can be associated with an increased risk of RP (2,3).
2. Patients with RP report a higher prevalence of migraine headache, and both variant angina and musculoskeletal chest pain (4) (Chapters 2.7 and 7.1).
Physical examination
A. Focused physical examination (PE). The goal of the PE is to uncover sentinel markers for illnesses responsible for secondary RP. In primary RP, the physical examination should be normal. Evaluate for thoracic outlet syndrome, examine distal extremity pulses, and perform an Allen test. Signs of scleroderma, such as sclerodactyly or telangiectasia should be sought, and digital necrosis or ulceration should be identified.
B. Additional PE. If the history suggests an underlying connective tissue disorder, examine the heart, lungs, joints, skin, and nervous system.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Raynaud Phenomenon:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Idiopathic
❑ Systemic lupus erythematosus
❑ Scleroderma
❑ Drugs
❑ Thoracic outlet syndrome
❑ Subclavian atherosclerosis
❑ Cryoglobulinemia
❑ Chronic vibration exposure
❑ Frostbite
Diagnostic Approach
Cold is the usual precipitant. A classic triphasic response, occurring in 20%, begins with sharply demarcated blanching of the extremities, followed by cyanotic (slate-blue) discoloration with a dull aching caused by vascular stasis. With rewarming, the digits become livid purple, then deep red. The radial pulse remains normal throughout. “White attacks” are consistent with true digital arterial closure whereas cyanosis or mottling may be caused by arteriovenous shunt closure or small arteriole vasospasm. Pain suggests severe tissue ischemia and an underlying disease. Raynaud phenomenon should be distinguished from the common phenomenon of cold hands or feet, without cutaneous color change.
Fever, arthralgias, or constitutional symptoms are subtle indicators of an emerging connective tissue disease. There may be a long interval between the initial appearance of Raynaud phenomenon and the diagnosis of a connective tissue disease.
Unilateral Raynaud phenomenon results from proximal vascular disease such as thoracic outlet syndrome or subclavian atherosclerosis. Unidigital Raynaud is due to trauma or embolism to the palmar artery.
Nailfold capillaries can be examined through a drop of oil using an ophthalmoscope set at 40 diopters. Enlarged or distorted capillary loops suggest an underlying connective tissue disease, or the potential to develop one. The findings below are for nailfold capillary microscopy in scleroderma, CREST, and mixed connective tissue disease.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Raynaud's disease:
Diagnosis
(Handbook of Diseases)
Criteria that help establish a diagnosis of Raynaud’s disease include skin color changes induced by cold or stress; bilateral involvement; absence of gangrene or, if present, minimal cutaneous gangrene; normal arterial pulses; and a patient history of signs and symptoms that last for more than 2 years. Blood flow studies and a cold stimulation test may be performed. The diagnosis must also rule out secondary disease processes, such as chronic arterial occlusive or connective tissue disease.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Tracheal tugging [Oliver-Cardarelli phenomenon, Oliver sign]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient isn't in distress, obtain a pertinent history. Ask about associated symptoms, especially pain, and about history of cardiovascular disease, cancer, chest surgery, or trauma.
Then examine the patient's neck and chest for abnormalities. Palpate the neck for masses, enlarged lymph nodes, abnormal arterial pulsations, and tracheal deviation. Percuss and auscultate the lung fields for abnormal sounds, auscultate the heart for murmurs, and auscultate the neck and chest for bruits. Palpate the chest for a thrill.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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