Clinical Challenge: Ring Finger Pain

History of Present Illness

A patient in his mid-60s with a history of end-stage renal disease (ESRD) presents to the emergency department (ED) with a 4-day history of left ring finger pain and discoloration. The patient denies any fever, injury, or other complaint.

Vital Signs and Physical Examination

The patient’s vital signs in the ED are essentially normal. Physical examination is normal except for the discoloration on his hand and a dialysis shunt in the opposite arm. The ring finger is tender and slightly cool but not swollen. Further testing and imaging such as electrocardiography (ECG) and radiograph of the affected finger are normal. Laboratory tests show baseline anemia that is unchanged and normal white blood cell count. The basic metabolic panel shows chronic kidney disease at baseline levels.