A 48-Year-Old Man With Swollen, Painful Areas on His Thumbs

Andrew Melone, MD; David F. Baehren, MD


January 06, 2020

Physical Examination and Workup

Upon physical examination, his oral temperature is 97.8°F (36.6°C), pulse is regular and with a rate of 74 beats/min, blood pressure is 151/90 mm Hg, and respiratory rate is 16 breaths/min. The patient is in mild distress due to pain from his hands. His sclerae are anicteric. The lungs are clear to auscultation, and the heart sounds are normal and without murmur, rub, or gallop. His abdomen is soft, nontender, and nondistended, with normal active bowel sounds and no hepatosplenomegaly. Examination of the hands reveals 2 discrete, tender nodules over the palmar aspect of the thumbs at the metacarpal-phalangeal joints bilaterally (Figures 1-2).

Figure 1.

Figure 2.

The nail beds of both hands are pale, but his radial pulses are normal bilaterally. His right leg has a well-healed knee amputation site, with no signs of erythema or induration.

Laboratory analysis reveals a hemoglobin level of 12.2 g/dL (122 g/L), hematocrit of 37% (0.37), a white blood cell count of 6.7 × 103/μL (6.7 × 109/L), a platelet count of 150 × 103/μL (150 × 109/L), a creatinine level of 1.15 mg/dL (101.66 μmol/L), a blood urea nitrogen (BUN) level of 13 mg/dL (4.64 mmol/L), and an erythrocyte sedimentation rate of 47 mm/hr. Electrocardiography reveals a normal sinus rhythm, with no ST- or T-wave abnormalities. The patient is given a normal saline bolus, ibuprofen, and morphine sulfate in the ED.


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