OSCE — Raynaud, skin thickening and SSc classification: diagnose and screen for organ crisis · MBBS OSCE

Brief (to candidate)

A 48-year-old woman has progressive Raynaud phenomenon for 3 years, puffy fingers, facial skin tightening and new dyspnoea on exertion. Blood pressure is normal today. A second card describes malignant hypertension with rising creatinine in a patient with diffuse skin thickening. You have 8 minutes to classify systemic sclerosis, organise autoantibody and organ screening, and manage renal crisis vs ILD/PAH pathways.

Candidate instructions

Define the pathophysiological triad and clinical gateway of SSc.
Distinguish limited (lcSSc) vs diffuse (dcSSc) cutaneous subsets and typical antibody links.
Apply 2013 ACR/EULAR classification framework and role of nailfold capillaroscopy.
List organ-screening priorities (ILD, PAH, GI, renal).
State emergency management of scleroderma renal crisis and steroid caution.

Examiner checklist (mark each domain / 10)

Domain	Key actions expected
Definition / triad	SSc = autoimmune CTD with microvascular vasculopathy, tissue fibrosis, and autoimmunity; Raynaud is the clinical gateway^[1]^[2]
Subsets	lcSSc: distal skin (face, neck, distal limbs distal to elbows/knees), CREST pattern, anti-centromere, late PAH risk. dcSSc: proximal trunk/limb involvement early, anti-Scl-70/RNA pol III, higher ILD and renal-crisis risk
Classification	ACR/EULAR 2013 weighted criteria (skin thickening of fingers, fingertip lesions, telangiectasia, abnormal nailfold capillaries, lung disease, Raynaud, SSc-related antibodies) — score ≥9 classifies SSc^[5]
Capillaroscopy / Abs	Scleroderma pattern on nailfold capillaroscopy (giant capillaries, haemorrhage, avascular areas, ramified capillaries); Abs: anti-centromere, anti-topo I (Scl-70), anti-RNA polymerase III^[6]
Organ screen	HRCT + PFTs for ILD; echo ± right-heart catheter pathway for PAH; GI symptoms; BP and renal function; skin score/mRSS when used
Renal crisis	New malignant HTN + AKI in SSc → start ACE inhibitor immediately (captopril classically); do not stop ACEI solely for rising creatinine; avoid high-dose steroids that may precipitate crisis
Therapy framing	Organ-based: mycophenolate/other immunosuppression and antifibrotics for progressive ILD as specialist care; vasodilators for Raynaud/PAH; EULAR 2023-aligned multidisciplinary care^[7]^[8]

Model key actions

Diagnose SSc using skin thickening + Raynaud + capillaroscopy/antibodies within ACR/EULAR framework.^[5]
Screen for ILD and PAH as major modern mortality drivers.^[8]
Treat renal crisis with ACE inhibitors immediately; warn against injudicious high-dose steroids.^[7]

Common errors

Confusing morphea (localised scleroderma) with systemic sclerosis.
Missing PAH/ILD screening in longstanding limited disease with dyspnoea.
Stopping ACEI in renal crisis because creatinine rises.
Using high-dose steroids without awareness of renal-crisis risk.
No nailfold capillaroscopy or autoantibody panel when diagnosing early disease.

References6Show

[1]Di Battista M, Lepri G, Codullo V, et al. Systemic sclerosis: one year in review 2025. Clinical and experimental rheumatology, 2025.PMID 40737082
[2]Jerjen R, Nikpour M, Krieg T, et al. Systemic sclerosis in adults. Part I: Clinical features and pathogenesis. Journal of the American Academy of Dermatology, 2022.PMID 35131402
[5]van den Hoogen F, Khanna D, Fransen J, et al. 2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative. Annals of the rheumatic diseases, 2013.PMID 24092682
[6]Smith V, Ickinger C, Hysa E, et al. Nailfold capillaroscopy. Best practice & research. Clinical rheumatology, 2023.PMID 37419757
[7]Del Galdo F, Lescoat A, Conaghan PG, et al. EULAR recommendations for the treatment of systemic sclerosis: 2023 update. Annals of the rheumatic diseases, 2025.PMID 39874231
[8]Maher TM. Interstitial Lung Disease: A Review. JAMA, 2024.PMID 38648021