A 65-year-old woman with known chronic obstructive pulmonary disease seeks evaluation due to pain in both of her knees and warmth in her fingertips. She has a 50-pack-year smoking history and quit 5 years ago. She has never been hospitalized for respiratory symptoms. The patient uses a tiotropium inhaler daily and albuterol as needed for shortness of breath. She also takes lisinopril for hypertension and bisacodyl for chronic constipation.
Her blood pressure is 144/85 mm Hg and pulse is 90/min. She has decreased breath sounds bilaterally and a mildly prolonged expiratory phase of respiration. There is a grade 1/6 systolic murmur along the left upper sternal border. The finger joints and both knees have some mild warmth and slight tenderness to palpation, with normal range of motion. Mild finger clubbing is present.
What is the best next step in management of this patient?

Question

A 65-year-old woman with known chronic obstructive pulmonary disease seeks evaluation due to pain in both of her knees and warmth in her fingertips.  She has a 50-pack-year smoking history and quit 5 years ago.  She has never been hospitalized for respiratory symptoms.  The patient uses a tiotropium inhaler daily and albuterol as needed for shortness of breath.  She also takes lisinopril for hypertension and bisacodyl for chronic constipation.
Her blood pressure is 144/85 mm Hg and pulse is 90/min.  She has decreased breath sounds bilaterally and a mildly prolonged expiratory phase of respiration.  There is a grade 1/6 systolic murmur along the left upper sternal border.  The finger joints and both knees have some mild warmth and slight tenderness to palpation, with normal range of motion.  Mild finger clubbing is present.
What is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's smoking history, clubbing, and symptoms of periosteal inflammation suggest hypertrophic osteoarthropathy (HOA), which is characterized by abnormal proliferation of the skin and osseous tissue. HOA is most commonly due to an intrathoracic process, frequently non-small cell lung cancer. Other intrathoracic causes of clubbing with hypertrophic osteoarthropathy include cystic fibrosis, chronic lung infections, and cyanotic heart disease with right-to-left intracardiac shunts. Patients presenting with HOA warrant thoracic imaging with chest x-ray or CT to rule out malignancy. Imaging of the painful joints would reveal periosteal new bone formation. (Choice B) Nonsteroidal anti-inflammatory drugs can relieve the pain. However, symptomatic therapy alone misses the opportunity to detect an underlying lung cancer. Resection of the mass may lead to resolution of joint symptoms in some patients. (Choice C) Chronic liver disorders, including cirrhosis, can lead to clubbing, but this is uncommon. (Choice D) Because most individuals with chronic obstructive pulmonary disease (COPD) are or have been smokers, there is a higher frequency of intrathoracic neoplasms in this population. However, COPD per se does not result in clubbing, and treating COPD with glucocorticoids or bronchodilators does not relieve HOA. (Choice E) Cyanotic heart disease with a right-to-left shunt can result in clubbing. This patient has a murmur that is likely due to age-related aortic sclerosis or mild aortic stenosis, but there are no additional cardiac findings that suggest a shunt. Educational objective: Hypertrophic osteoarthropathy usually involves distal parts of the extremities and is characterized by abnormal proliferation of the skin and osseous tissue. It presents with clubbing of the fingers and synovitis of knees, ankles, and fingers. The most common cause is an intrathoracic neoplasm. __________ References: Nail abnormalities: clues to systemic disease. (http://www.ncbi.nlm.nih.gov/pubmed/15053406) Mutation in 15-hydroxyprostaglandin dehydrogenase gene causes hypertrophic osteoarthropathy. (http://www.ncbi.nlm.nih.gov/pubmed/18500342)

A 65-Year-Old Woman with Known Chronic Obstructive Pulmonary Disease Seeks