Chronic Shoulder Pain and Fingernail Clubbing in a Middle-Aged Man
Published on Diagnostic Imaging (http://www.diagnosticimaging.com)
Chronic Shoulder Pain and Fingernail Clubbing in a Middle-Aged
Man
What's Your Diagnosis [1] | April 06, 2012
By Brady Pregerson, MD [2]
What is causing this clubbing of the fingernails, and what is it called?
A middle-aged man who
works as a janitor presents to the emergency department (ED) with intermittent right shoulder pain
that has been present for about 5 months. Motion can exacerbate the pain, but sometimes the
shoulder hurts even when he is doing nothing. The pain wakes him at night. The patient has made
previous visits to the ED because of this pain and radiographs were taken of the shoulder; the
diagnosis was tendinitis.
The patient denies chest pain, shortness of breath, fever, or other symptoms. His medical history is
notable only for hypertension for which he takes labetalol. He had asthma as a child. He has smoked
roughly a pack of cigarettes every 2 to 3 days for 35 years and he drinks socially. He denies use of
illicit drugs.
The patient appears to be in no acute distress and his vital signs are normal except for a blood
pressure of 163/101 mm Hg. Head and neck examination are unremarkable and the heart and lungs
sounds are normal. His abdomen is scaphoid, without mass or tenderness. Examination of the right
shoulder demonstrates no deformity and a full range of motion. Impingement testing elicits pain
consistent with tendinitis/bursitis. The patient’s radial pulse is strong, and distal motor and sensory
neurologic function is intact.
A check of the patient’s finger strength reveals abnormal looking fingernails (Figure 1).
To what diagnosis does a history of chronic shoulder pain and recent onset of fingernail clubbing
point?
Click here for answer and discussionAnswer: Nail Clubbing Secondary to Lung Cancer
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Chronic Shoulder Pain and Fingernail Clubbing in a Middle-Aged Man
Published on Diagnostic Imaging (http://www.diagnosticimaging.com)
Chronic shoulder pain with recent onset
of fingernail clubbing can be an ominous sign, in this case heralding the presence of lung cancer.
Lung tumors, especially Pancoast tumors, not infrequently mimic musculoskeletal conditions of the
shoulder. Consider adding a chest film to the workup of shoulder pain in the proper clinical setting or
when there are no positive findings on examination of the shoulder.
Table 1 lists the differential diagnostic considerations of shoulder pain. Table 2 offers some useful
tips about fingernails.
It is uncertain whether this patient also had tendinitis: visceral conditions, including coronary artery
disease can occasionally aggravate preexisting musculoskeletal conditions. Therefore, be wary of
ending your diagnostic process prematurely when a second condition may be present. Chest films
for this patient show a pulmonary mass at the right hilar area (Figure 2).
Table 1. Quick essentials on shoulder pain differential diagnosis
Anterior: Acromio-clavicular joint arthritis, glenohumeral joint arthritis, biceps
tendinitis
Posterior: Neck conditions, suprascapular nerve entrapment
Lateral: Impingement, tendinitis, rotator cuff (all usually aggravated by reaching
overhead)
Other: Brachial plexus, vascular disease, thoracic outlet syndrome, lung tumor,
myocardial infarction, abdominal aortic aneurysm, pericarditis, GI disease
Table 2.Quick essentials on fingernail conditions
Fingernails: Made of keratin. Average growth rate: 3 mm/mo for fingers; 1
mm/mo for toes
White lines: Muehrcke lines: low albumin; Mees lines: arsenic; nail base lines:
paraneoplastic disease
Fungus: Trichophyton rubrum infection in 90%. Risks: tight shoes, peripheral
vascular disease, HIV infection, tobacco. Rx: terbinafine (≈ 45% relapse at 3 years)
Clubbing: "CLUB": Congenital, Cardiac, Cirrhosis, Lung disease, Ulcerative colitis,
Biliary disease
Other: HIV infection, hyperthyroidism
From Quick Essentials Emergency Medicine pocketbook, copyright EMresource.org
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Chronic Shoulder Pain and Fingernail Clubbing in a Middle-Aged Man
Published on Diagnostic Imaging (http://www.diagnosticimaging.com)
Source URL:
http://www.diagnosticimaging.com/whats-your-diagnosis/chronic-shoulder-pain-and-fingernail-clubbi
ng-middle-aged-man
Links:
[1] http://www.diagnosticimaging.com/whats-your-diagnosis
[2] http://www.diagnosticimaging.com/authors/brady-pregerson-md
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