A Native American man aged 40 years has a very tender right rib cage cystic formation that measures 2.0 x 2.0 x 0.5 cm. Extensive workup has found nothing. He has profoundly clubbed fingers and toes (without abnormal facies), a severely congested cough, cachexia, fatigue and depression. He spends most of every day in bed and tells me that he feels like he’s dying.

Thyroid tests, MRI, CT and x-ray performed two years ago were negative (except to reveal hyper-expanded airways). I have ordered an MRI of the cyst and a repeat chest x-ray. He was sent to me for pain management, and I have initiated duloxetine (Cymbalta) and oxycodone. What are my other options? — Jan Morgan, ARNP, FAAPM, Bremerton, Wash.

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This is a challenging clinical scenario. It is not clear if this patient’s symptoms are related or if there is more than one diagnosis to explain his condition. Since you included the dimensions, I assume that the rib cage cystic mass is palpable. If so, despite the fact that the MRI, CT and x-ray are negative, a biopsy of a palpable mass can be diagnostic.

Clubbed fingers and toes can be attributable to a congenital problem or secondary to heart, lung, liver or thyroid disease. This patient displays many symptoms of chronic obstructive pulmonary disease (COPD), which includes both chronic bronchitis and emphysema. Smoking, genetics and environmental and occupational exposures are risk factors for COPD. Alpha-1 antitrypsin is a protein that protects the lungs, and a deficiency can result in the development of COPD, especially in a younger person.

Classic symptoms of COPD include chronic cough with sputum production, fatigue and decreased appetite from the increased work of breathing. Patients with COPD may limit their activity in an attempt to avoid exertional dyspnea, a common early symptom of COPD. Depression is often associated with chronic illness and can also account for symptoms of fatigue and loss of interest in activities.

Hyper-expanded airways on x-ray are caused by air trapping and are characteristic of emphysema. I would recommend pulmonary function testing for this patient. Pulmonary function tests can make the diagnosis of COPD, determine the severity of the disease and distinguish it from asthma. Also, consider testing for an alpha-1 antitrypsin deficiency. While there is no cure for COPD, there are many treatments available to help control the symptoms and improve quality of life. — Eileen F. Campbell, MSN, CRNP (161-2)

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