Recurrent Colour Change in Her Fingers — Free SCA Practice Case
Musician with recurrent colour change in her fingers
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Materials for Candidate
Please review before starting the consultation
Full Name
Naomi Adebayo
Age
28 years
Consultation Type
TelephoneAge
28
Situation
Telephone Consultation.
Reason for Encounter
"My hands keep changing colour and it's getting worse. It happens when I play, and I've got a big performance coming up."
Medical Records
- ●PMH: None recorded.
- ●Medications: None.
- ●Allergies: NKDA.
- ●Recent contact: No significant recent consultations.
Patient Script
For the friend playing the patient role
Character Overview: You are Naomi, a 28-year-old professional clarinettist who plays at weddings and exclusive events. For about four years — worse in the last six months — your hands change colour: first white, then blue, then red. When white or blue they feel numb; when they turn red they are painful. You have noticed it happens when you play the clarinet, and it settles about 15 minutes after you stop. You smoke around 15 cigarettes a day (for five years). You were adopted, so you do not know your family history. You have an important performance on a big stage in four weeks and are worried it will affect you.
Opening Sentence: "Hi Doctor. I keep getting problems with my hands — they change colour, and it's been getting worse. They go white, then blue, then red, and they're numb and then painful. It seems to happen when I'm playing my clarinet. I've got a big performance in four weeks and I'm worried."
History if Asked (Data Gathering Phase)
- ●The colour change: "They go white first, then blue, then red — in that order. Numb when they're white or blue, then painful when they go red."
- ●Both hands: "Both hands, yes, mainly the fingers."
- ●Duration/course: "About four years, but noticeably worse in the last six months."
- ●Trigger: "I've realised it's when I play the clarinet — the repetitive finger movements. If I stop, it settles after about 15 minutes."
- ●Impact: "I'm a professional musician. I've got a big performance in four weeks and I'm frightened it'll ruin it."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.
- ●Ideas: Naomi is unsure what the condition is. "I honestly don't know what this is."
- ●Concerns: Her dominant concern is the upcoming performance and her career — that this will affect her playing on a big stage. "My worry is my performance in four weeks — my career depends on my hands."
- ●Expectations: She wants to know what it is and how to manage it. "I'd like to know what it is and what can be done."
If Asked — Raynaud's and Secondary-Cause Screen
The patient answers these only when directly asked.
- ●If asked about the classic triphasic sequence and recovery time: "White, then blue, then red, settling about 15 minutes after I stop playing." (Classic Raynaud's.)
- ●If asked about triggers other than playing (cold, stress): "Cold makes it more likely too, and maybe stress, but playing is the main trigger."
- ●If asked about other areas affected (nose, ears): "Just the fingers, not my nose or ears."
- ●If asked about finger ulcers or skin tightening/thickening (sclerodactyly): "No ulcers, and my skin feels normal — not tight or thickened." (Screens against secondary Raynaud's/scleroderma.)
- ●If asked about difficulty swallowing, reflux, or lumps under the skin (CREST features): "No swallowing problems, no reflux, no lumps."
- ●If asked about joint pains, rashes, dry eyes/mouth (autoimmune features): "No joint pains or rashes, no dryness."
- ●If asked about smoking: "I smoke about 15 a day, have done for five years."
- ●If asked about family history: "I was adopted, so I don't know my family history."
- ●If asked about vibrating tools or other occupational exposures: "No power tools — just the clarinet."
Responses to Management (The Negotiation Phase)
- ●If the Doctor explains this is Raynaud's phenomenon: "Raynaud's? I've not heard of it. What actually is it?" (The tested point is explaining Raynaud's — vasospasm of the small vessels — and the triphasic colour change.)
- ●If the Doctor offers a face-to-face examination and bloods: "What will examining me change, when I don't have the symptoms now and it only happens when I play?" (The tested point is explaining why examination — pulses, blood pressure — and blood tests to screen for secondary causes matter before treatment.)
- ●If the Doctor advises smoking cessation — the key modifiable factor: "Would stopping smoking really make a difference to my hands?" (The tested point is explaining that smoking worsens Raynaud's and offering cessation support.)
- ●If the Doctor discusses medication (nifedipine): "Is there a treatment that would help before my performance?"
- ●If the Doctor gives self-management advice: "Is there anything I can do myself, especially before and during playing?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Raynaud's Phenomenon
- ●Raynaud's phenomenon is episodic vasospasm of the digital vessels, classically producing a triphasic colour change (white → blue → red) with numbness (white/blue) then pain (red) on recovery. Triggers include cold, stress, vibrating tools, and repetitive finger use (here, clarinet playing).
Primary vs Secondary Raynaud's
- ●Primary Raynaud's occurs alone and is usually benign. Secondary Raynaud's is associated with connective-tissue disease (e.g. systemic sclerosis/CREST, SLE). Screen for finger ulcers, skin tightening/sclerodactyly, calcinosis, telangiectasia, dysphagia, joint pains, and sicca symptoms, and arrange an autoimmune screen (including ANA). Ulcers or skin changes point to a secondary cause.
Assessment
- ●Examine the pulses and blood pressure (before treatment), arrange screening bloods, and suggest photographs during an episode to document the changes.
Smoking — the Key Modifiable Factor
- ●Smoking worsens Raynaud's by impairing circulation. Smoking cessation is a central modifiable intervention — offer support.
Self-Management
- ●Advise keeping warm, warming the hands before triggering activities, using gloves/hand-warmers, and avoiding cold/stress triggers, tailored to the person's occupation.
Medication
- ●Nifedipine (a calcium-channel blocker) is first-line for troublesome Raynaud's, relaxing the vessels; counsel on light-headedness/flushing. Reserve for symptoms not controlled by conservative measures.
Occupational Impact
- ●Take the occupational impact seriously (here, a professional musician) and tailor advice and treatment accordingly.
Common Candidate Mistakes in This Case
- ●Not screening for secondary Raynaud's: missing the essential primary/secondary distinction.
- ●Not justifying examination/bloods: allowing the patient to decline appropriate assessment.
- ●Omitting smoking cessation: missing the key modifiable factor.
- ●Ignoring the occupational/performance concern: failing to tailor the plan to a musician.
- ●Prescribing without counselling, or missing first-line options: poor medication management.