A 50-year-old patient with long-standing chronic obstructive lung disease develops the insidious onset of aching in the distal extremities, paicularly the wrists bilaterally. There is a 9kg weight loss. The skin over the wrist is warm and erythematous. There is bilateral clubbing. Plain film is read as periosteal thickening, possible osteomyelitis. You should

(Braunwald, 15/e, pp 2008- 2010.) The clinical picture suggests hyperophic osteoahropathy. This process, the pathogenesis of which is unknown, is characterized by clubbing of digits, periosteal new bone formation, and ahritis. Hyperophic osteoahropathy is associated with intrathoracic malignancy, suppurative lung disease, and congenital hea problems. Treatment is directed at the underlying disease process. While x- rays may suggest osteomyelitis, the process is usually bilateral and easily distinguishable from osteomyelitis. The first step in evaluation of this patient is to obtain a chest x-ray looking for lung infection and carcinoma.