Chronic Shoulder Pain and Fingernail Clubbing in a Middle-Aged Man

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(Drug information on 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 discussion