History and Physical Examination
A 72-year-old woman with a history of hypertension and metastatic bladder cancer is referred to the hospital emergency department (ED) by her primary care provider with a complaint of 3 to 4 weeks of gradually worsening bilateral finger pain and cyanosis associated with a 15-lb weight loss. She denies any fever, cold exposure, palpitations, or other complaints.
On examination, the patient is cachectic but appears well hydrated. She has normal vital signs except for her pulse, which is borderline in the 90s. Examination of her head and neck is normal, as is examination of her chest and abdomen. Her extremities have good peripheral pulses, but her fingers are cool and discolored.
Initial concerns include vasculitis, ischemia, infection, emboli, or frostbite. The patient underwent testing in the ED, which revealed the following:
- Electrocardiography was normal without ectopy
- Liver function tests and basic metabolic panel were normal
- Complete blood count was normal except for a platelet count of 572,000/µL
- C-reactive protein level and erythrocyte sedimentation rate were both extremely elevated
What does the image show? What should be your next step?
Click to the next page for answers.