History Taking · Foundation · Rheumatology

Finger Discoloration in a 45-Year-Old Woman

Practise this PLAB 2 history taking station on Primary Raynaud's Phenomenon. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in general practice. Mrs Irina Stein, a 45-year-old woman, has come to see you with colour changes in her fingers when exposed to cold. She is worried that this might be part of something more serious. Please take a focused history to differentiate primary from secondary Raynaud's phenomenon and discuss your initial assessment.

Background notes: PMH: Nil significant

What this station tests

  • Screening for secondary Raynaud's: scleroderma (skin thickening, dysphagia), lupus (photosensitive rash, joint pain), and other connective tissue diseases
  • Features supporting primary Raynaud's: bilateral, symmetrical, no tissue damage, no systemic features, stable over years
  • ANA and nailfold capillaroscopy as the key investigations: ANA screens for CTD, abnormal capillaroscopy suggests secondary
  • Practical cold avoidance advice: gloves, hand warmers, core warmth, avoiding cold water
  • Nifedipine as first-line pharmacological treatment for severe primary Raynaud's

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Raynaud's stations test whether the candidate can distinguish primary (benign) from secondary (associated with connective tissue disease) Raynaud's. The critical task is screening for scleroderma and lupus. Mrs Stein is 45, presenting with 5 years of cold-triggered colour changes in her fingers (white to blue to red). She is worried because a friend's sister had Raynaud's as part of scleroderma. Open with: 'Mrs Stein, tell me about the colour changes and what triggers them.'

Core approach

Characterise the Raynaud's. Classic triphasic colour change: white (vasospasm), blue (deoxygenation), red (reperfusion). Bilateral and symmetrical. Triggered by cold exposure and emotional stress. Episodes last minutes to an hour. Associated numbness and tingling during attacks. Pain during reperfusion phase. No tissue damage (no ulcers, no gangrene). Duration: 5 years without progression.

Screen for secondary causes (the key diagnostic task). Scleroderma: any skin thickening or tightness? Difficulty opening mouth? Dysphagia? Heartburn? Breathlessness? Sclerodactyly? Lupus: photosensitive rash? Joint pain? Mouth ulcers? Pleurisy? Kidney problems? Mixed connective tissue disease, dermatomyositis, Sjogren's: dry eyes, dry mouth, muscle weakness?

Features suggesting primary (benign) Raynaud's in this case: onset in her 40s (though primary typically starts younger), bilateral and symmetrical, no systemic features, 5 years without progression or tissue damage. No nail fold changes (if examined). ANA may be checked (often weakly positive in primary Raynaud's without clinical significance).

PMH: nothing significant. No medications that could cause Raynaud's (beta-blockers, ergotamine).

Closing and safety netting

Reassure based on the absence of secondary features: 'Mrs Stein, the colour changes you describe are Raynaud's phenomenon. Based on your history, the fact that both hands are equally affected, you have had it for 5 years without any skin changes or other symptoms, and there is nothing in your health history to suggest an underlying cause, this is most likely primary Raynaud's, which is benign.'

Investigations to confirm: ANA (screening for connective tissue disease), ESR/CRP, FBC, U&E. Nailfold capillaroscopy if available (abnormal in secondary Raynaud's). If all normal, primary Raynaud's is confirmed.

Management: avoid cold exposure (gloves, hand warmers, avoid cold water), keep core body temperature warm, avoid smoking (vasoconstriction), avoid caffeine. If severe: nifedipine (calcium channel blocker) is first-line pharmacological treatment. Safety net: 'If you develop any skin changes on your fingers (ulcers, thickening), difficulty swallowing, joint pain, or a facial rash, come back as these could suggest an underlying condition that would need different management.' Annual review.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for primary raynaud's phenomenon. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Triphasic colour change confirmed. Secondary screening performed (scleroderma, lupus, other CTD). Duration and stability documented. Medication review. Tissue damage excluded. Symmetry noted.

Costs marks: Not screening for secondary causes. Not documenting triphasic pattern. Not checking medications.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: ANA and basic bloods arranged. Primary Raynaud's diagnosed with clear rationale. Cold avoidance advice. Nifedipine for severe cases. Safety netting for secondary features. Annual review planned.

Costs marks: Over-investigating. Not providing practical advice. No safety netting for secondary development.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Directly addressing her friend's scleroderma concern. Providing firm, specific reassurance based on the absence of secondary features. Practical advice she can implement immediately.

Costs marks: Not addressing the scleroderma concern. Hedging reassurance. Generic advice.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not screening for secondary causes. The entire diagnostic value of this station is distinguishing primary from secondary Raynaud's. Candidates who diagnose Raynaud's without asking about scleroderma, lupus, and other connective tissue disease features miss the point.
  2. Over-investigating benign Raynaud's. If the history is classic for primary Raynaud's (bilateral, symmetrical, no systemic features, stable for years), extensive autoimmune panels are not needed. ANA and basic bloods are sufficient.
  3. Not addressing her friend's story. She came in specifically because her friend's sister had Raynaud's as part of scleroderma. If the candidate does not address this concern directly, she leaves with the same anxiety she arrived with.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take a primary raynaud's phenomenon history in PLAB 2?

Raynaud's stations test whether the candidate can distinguish primary (benign) from secondary (associated with connective tissue disease) Raynaud's. The critical task is screening for scleroderma and lupus. Mrs Stein is 45, presenting with 5 years of cold-triggered colour changes in her fingers (white to blue to red).

Where are marks won and lost in this primary raynaud's phenomenon station?

Examiners reward: Triphasic colour change confirmed. Secondary screening performed (scleroderma, lupus, other CTD). Duration and stability documented. Medication review. Tissue damage excluded. Candidates are penalised for: Not screening for secondary causes. Not documenting triphasic pattern. Not checking medications.

Where do candidates most often go wrong in this station?

Not screening for secondary causes. The entire diagnostic value of this station is distinguishing primary from secondary Raynaud's. Candidates who diagnose Raynaud's without asking about scleroderma, lupus, and other connective tissue disease features miss the point.

Can I do well in this station without real-world experience of primary raynaud's phenomenon?

Structure beats experience here. Focus on features supporting primary Raynaud's: bilateral, symmetrical, no tissue damage, no systemic features, stable over years. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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