SCA practice case · Video consultation
“Her fingers go dead white then blue in the cold — is it just poor circulation?”
Video consultation
Young person patient
Someone else speaking
Typical
Children & young peopleNew & undifferentiated presentations
The candidate brief
This is what you would read in the 3-minute window before the patient connects. Read it once, note two or three hypotheses and one thing you must not miss, then stop.
Patient
Ruby Hartnell · 15 years · female
Setting
Video consultation — teenager with colour-changing fingers, mother present.
Past history
- Nil relevant recorded
Medication
- No regular medication
Allergies
None recorded
Recent notes
⚠ Two winters of white–blue–red finger colour change in the cold, pain on rewarming, full recovery between attacks. No bloods on file.
Reason for contact
Mother: “Is it just poor circulation — or her heart?”
Practise this case
The full case is in the Hot Seat with the Gold plan. You get a 12-minute timer, a role-player script with facts released only when asked, examiner checkpoints by the three RCGP domains, a model consultation and the guidance behind it.
What this case tests
Show the learning points (spoiler: read after you have practised)
The triphasic digital colour change — WHITE (vasospasm) → BLUE (cyanosis) → RED (reperfusion) — on cold/stress exposure, with numbness/pain and full recovery between attacks, is RAYNAUD’S PHENOMENON, and the key examinable skill is distinguishing PRIMARY from SECONDARY disease. PRIMARY (idiopathic) Raynaud’s is common and benign: onset in the teens/twenties, typically female, symmetrical, with no tissue damage (no digital ulcers/pits/gangrene), normal nailfold capillaries, no systemic features, and negative autoantibodies/normal inflammatory markers. SECONDARY Raynaud’s points to an underlying connective tissue disease (systemic sclerosis/scleroderma, SLE, mixed CTD) and is flagged by later onset (>30–40), asymmetry, severe attacks, digital ulcers/pitting scars/gangrene, abnormal nailfold capillaries, and associated features (arthralgia, skin tightening/puffiness, malar or photosensitive rash, dry eyes/mouth, dysphagia/reflux, mouth ulcers, hair loss, fatigue) — so screen these actively. Investigations are proportionate: examine hands, nailfolds, pulses and BP face to face (not possible on video); a purely primary picture with normal examination needs little, though FBC, ESR/CRP and ANA (± ENA) reasonably support the diagnosis and catch early CTD; any secondary red flag or positive autoantibodies warrants these bloods and rheumatology referral. Manage primary Raynaud’s conservatively first — keep the whole body warm (gloves, hand warmers, layers, avoid sudden cold), stop smoking (including household exposure), limit caffeine and avoid precipitant drugs — with nifedipine the usual first drug if attacks are frequent/severe (licensed for adults only, so off-label and specialist-advised under 18, dose per BNFC), reassuring that primary Raynaud’s does not damage the fingers while safety-netting for same-day assessment of a digit that will not rewarm or new ulceration/necrosis (BSR 2024). Engage the teenager directly about real-life impact (school, PE, self-image), offer her time on her own, and reassure the anxious parent proportionately.
The guidance behind it
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