A 45-year-old man presents with two days of bilateral hand pain that is most severe in his wrists. Physical examination reveals bilateral wrist tenderness, thickening of the distal fingers, and convex nail beds. There is nicotine staining of the right index and middle fingers. He states that he has been smoking 2 packs of cigarettes a day for the past 25 years. Chest examination reveals decreased breath sounds and a prolonged expiratory phase. The patient relates the pain's onset to a data entry job he recently started. He notes that his boss believes he is fabricating his pain to get off work. His job record reveals numerous sick leaves. Which of the following is the most appropriate course of action?

Question

A 45-year-old man presents with two days of bilateral hand pain that is most severe in his wrists.  Physical examination reveals bilateral wrist tenderness, thickening of the distal fingers, and convex nail beds.  There is nicotine staining of the right index and middle fingers.  He states that he has been smoking 2 packs of cigarettes a day for the past 25 years.  Chest examination reveals decreased breath sounds and a prolonged expiratory phase.  The patient relates the pain's onset to a data entry job he recently started.  He notes that his boss believes he is fabricating his pain to get off work.  His job record reveals numerous sick leaves.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

This patient presents with an extensive smoking history and evidence of COPD and digital clubbing on physical exam. Though he associates his wrist pain with his data entry job, it may be a sign of underlying lung disease. Hypertrophic osteoarthropathy (HOA) is a condition where digital clubbing is accompanied by sudden-onset arthropathy, commonly affecting the wrist and hand joints. Hypertrophic pulmonary osteoarthropathy (HPOA) is a subset of HOA where the clubbing and arthropathy are attributable to underlying lung disease like lung cancer, tuberculosis, bronchiectasis, or emphysema. Given this patient's smoking history, lung cancer should be of particular concern. Chest x-ray (Choice B) is an appropriate initial study for identifying the underlying cause of his suspected HPOA. Educational objective: The development of clubbing and sudden-onset joint arthropathy in a chronic smoker is suggestive of hypertrophic osteoarthropathy. This condition is often associated with lung cancer, and therefore a chest x-ray is indicated to rule out malignancy and/or other lung pathology.

A 45-Year-Old Man Presents with Two Days of Bilateral Hand