Differential Diagnosis for Discoloration and Skin Changes in Fingers

The patient presents with discoloration and skin changes in her fingers, which have worsened over the last few days. Given her history and symptoms, the following differential diagnoses are considered:

• Single Most Likely Diagnosis
  • Raynaud's Phenomenon: This condition is characterized by a sudden and temporary narrowing of the arteries, leading to discoloration of the fingers and toes. The patient's symptoms of discoloration and skin changes, particularly the worsening over the last few days, are consistent with Raynaud's. The fact that she has been seen by vascular and rheumatology suggests that an autoimmune or vascular component is being considered.
• Other Likely Diagnoses
  • Systemic Sclerosis (Scleroderma): This autoimmune disease can cause Raynaud's phenomenon, skin thickening, and digital ulcers, which may explain the patient's skin changes on her right hand.
  • Vasculitis: Inflammation of the blood vessels can lead to skin changes, discoloration, and potentially digital ischemia. The patient's symptoms and history of being seen by rheumatology suggest that vasculitis is a possible diagnosis.
  • Hypothyroidism: This condition can cause cold intolerance, dry skin, and potentially Raynaud's phenomenon, which may contribute to the patient's symptoms.
• Do Not Miss Diagnoses
  • Acute Arterial Occlusion: A sudden blockage of an artery can cause severe ischemia, leading to pain, discoloration, and potentially gangrene. Although less likely, this diagnosis is critical to rule out due to its high morbidity and mortality.
  • Sepsis or Infection: Infection can cause vasculitis, septic emboli, or direct infection of the digits, leading to skin changes and discoloration. Given the patient's worsening symptoms, sepsis or infection must be considered and ruled out.
• Rare Diagnoses
  • Buerger's Disease (Thromboangiitis Obliterans): A rare disease characterized by inflammation and clotting of small and medium-sized blood vessels, which can cause skin changes, discoloration, and digital ischemia.
  • Ehlers-Danlos Syndrome: A genetic disorder that can cause blood vessel fragility, leading to aneurysms, dissections, or other vascular complications, which may contribute to the patient's symptoms.

Workup in the Emergency Department

The workup should include:

• Complete blood count (CBC) to rule out infection or inflammation
• Electrolyte panel and renal function tests to assess for any underlying metabolic disorders
• Thyroid function tests to evaluate for hypothyroidism
• Inflammatory markers (e.g., erythrocyte sedimentation rate, C-reactive protein) to assess for vasculitis or other autoimmune diseases
• Imaging studies (e.g., Doppler ultrasound, angiography) to evaluate blood flow and rule out arterial occlusion
• Consultation with rheumatology and vascular surgery to further evaluate and manage the patient's condition.