Hey, folks, just a quick reminder that this podcast is not meant to be used for medical advice,

just good old-fashioned education.

Welcome back to the clinical problem solvers.

My name is Reza Minesh. I'm a clinician educator at

Johns Hopkins Hospital. I'm very excited in bringing you tonight's show. It's a clinical unknown,

and we have our mathematician Robbie Gija in the hot seat. Tonight's case presenter is Dr. Aaron Chu.

Dr. Aaron Chu graduated from Baylor College of Medicine.

She is an intern in the Internal Medicine residency training program at Johns Hopkins Hospital.

She is from Orlando, Florida, and enjoys family vacations at the beach, watching British dramas, and hanging out with her co-interns. Dr. Aaron Chu did a phenomenal

job of preparing and presenting this case. Thank you so much, Dr. Chu. Try to solve the case in parallel

with Dr. Gihaw. Let's see if he can overcome tonight's challenge. Enjoy. A 23-year-old woman presented with two

months of progressive digit discoloration in a one-month history of fingertip ulceration. Two months

ago, she started having episodes of finger discoloration and pain. During these episodes, her digit

discoloration progressed from pale to blue to red. Each

episode affected all digits of both hands usually occurred after exposure to the cold and lasted

about 20 minutes. One month ago, she started to notice that her finger discoloration persisted and ulcerations formed on several

digits of both hands with worsening pain, erythema, and tenderness. She also had new circular

erythematous, non-tender, non-preritic lesions on her upper thighs and shoulders, bilaterally

that progressively enlarged and became confluent.

All right. Wow. A fascinating start to the case. So there's a couple of things to parse out.

I've one to recognize that we're dealing with a young patient and automatically I pause and remind myself that while the vast majority

of patients that I see will have internal medicine diagnoses, it's important to recognize that

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