History:

Patient of Dr 

59 yo male Australian that has always worked "on the tools" and currently manufacturing trailers complains of a couple of months history of dark lesion over tip of third finger R hand that got worse in the last week. Patient is on severe pain

On physical exam evidence of cold finger with purple color and dark lesion in tip of finger

PMH of HT, dyslipidaemia and Sjogren Syndrome
on dual antihypertensive therapy and statins
Patient is a heavy smoker

IM Tramadol was applied and patient was sent to ED for further studies and management. Seen by ED registrar and dermatologist. Started on IV antibiotic and discharged home with follow up 6 weeks after with outpatient dermatology clinic

Patient was still on severe pain and skin lesion was deteriorating with clear ischemia to the point of gangrena and deep ulceration. Blood test were done with a positive finding of antinuclear factor in a titre of 1:1280 in a centromere pattern suggesting possibility of localised scleroderma. Referred to Rheumatologist

Rheumatologist concept:
- to encourage cease smoking
- to remove part of his finger but recommended that he should receive IV prostaglandins prior surgery to optimise digital blood flow

Patient accepted for surgery, hospitalised prior surgery for IV prostaglandins, necrotic end of finger was removed. Pain resolved completely. Proper healing

Because people with limited scleroderma tend to have free oesophageal reflux which can give them oesophageal strictures, Losec 20mg was prescribed to the patient and a recommendation for follow up in 6 months for an echocardiogram to make sure there is no evidence of pulmonar hypertension.