A 45-Year-Old Man Presents with Two Days of Bilateral Hand

A 45-year-old man presents with two days of bilateral hand pain that is most severe in his wrists.  Physical examination reveals bilateral wrist tenderness, thickening of the distal fingers, and convex nail beds.  There is nicotine staining of the right index and middle fingers.  He states that he has been smoking 2 packs of cigarettes a day for the past 25 years.  Chest examination reveals decreased breath sounds and a prolonged expiratory phase.  The patient relates the pain's onset to a data entry job he recently started.  He notes that his boss believes he is fabricating his pain to get off work.  His job record reveals numerous sick leaves.  Which of the following is the most appropriate course of action?

A) Reassure the patient and prescribe analgesics
B) Obtain chest x-ray
C) Obtain rheumatoid factor levels
D) Recommend psychiatry evaluation
E) Order serum calcium and uric acid levels

Correct Answer:

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