Snapshot A 60-year-old man presents to his primary care physician with hip pain and hearing loss. He denies any trauma to the hip or any recent changes in his medications. He also notes his hat fits tighter than before. Physical examination is unremarkable. Laboratory testing is significant for an elevated alkaline phosphatase level in the setting of normal serum calcium, phosphate, and parathyroid hormone. Introduction Clinical definition a progressive metabolic bone disorder of abnormal bone remodeling excessive bone resorption and formation is present Epidemiology incidence second most common metabolic bone disorder (osteoporosis is first) age > 55 years of age Etiology unknown Pathogenesis increased multinucleated osteoclastic and osteoblastic activity leads to a high bone remodeling rate resulting in abnormal bone architecture (lytic and blastic lesions) Prognosis expansion of untreated Paget lesions Presentation Symptoms usually asymptomatic bone and/or joint pain bone deformity bowing deformity hearing loss with skull involvement that leads to narrowing of the auditory foramen Physical exam typically unremarkable Imaging Radiography indication to identify osteolytic, osteoblastic, and sclerotic bone changes Bone scintigraphy indication to determine the extent of Paget disease of bone and to assess for other sites of involvement Studies Labs normal serum phosphate, calcium, and parathyroid hormone elevated alkaline phosphatase Histology mosaic pattern of lamellar bone with prominent cement lines Differential Laboratory Abnormalities in Select Bone Disorders Etiology Serum Phosphate Serum Calcium Serum Alkaline Phosphatase Parathyroid Hormone Osteomalacia/rickets Decreased Decreased Increased Increased Osteoporosis Normal Normal Normal Normal Osteopetrosis Normal Normal or decreased Normal Normal Paget disease of the bone Normal Normal Increased Normal Osteitis fibrosa cystica Primaryhyperparathyroidism• decreasedSecondaryhyperparathyroidism• increased Primaryhyperparathyroidism• increasedSecondaryhyperparathyroidism• decreased Primary and secondary hyperparathyroidism• increased Primary and secondary hyperparathyroidism• increased Hypervitaminosis D Increased Increased Normal Decreased Treatment Medical bisphosphonates indication first-line treatment for Paget disease of bone Surgical orthopedic surgery (e.g., joint/knee arthroplasty) indication to manage symptomatic complications of Paget disease of bone (e.g., osteoarthritis, pathologic and pseudofractures, and spinal stenosis) Complications Neurologic nerve root compression hearing loss spinal stenosis Orthopedic pathologic fractures secondary osteoarthritis Oncologic osteosarcoma Cardiovascular high-output heart failure abnormal bone deposition leads to increased bony vascularization, which decreases systemic vascular resistance (afterload), leading to high-output heart failure
QUESTIONS 1 of 8 1 2 3 4 5 6 7 8 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.OR.4867) A 52-year-old man presents to his primary care physician for generalized pain. The patient states that he feels like his muscles and bones are in constant pain. This has persisted for the past several weeks, and his symptoms have not improved with use of ibuprofen or acetaminophen. The patient has a past medical history of alcohol abuse, repeat episodes of pancreatitis, constipation, and anxiety. He has a 22 pack-year smoking history. His temperature is 99.5°F (37.5°C), blood pressure is 140/95 mmHg, pulse is 70/min, respirations are 15/min, and oxygen saturation is 99% on room air. On physical exam, you note generalized tenderness/pain of the patient's extremities. Abdominal exam reveals normoactive bowel sounds and is non-tender. Dermatologic exam is unremarkable. Laboratory values are ordered as seen below.Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 7,500/mm^3 with normal differential Platelet count: 147,000/mm^3 Serum: Na+: 138 mEq/L Cl-: 100 mEq/L K+: 4.2 mEq/L HCO3-: 24 mEq/L BUN: 20 mg/dL Glucose: 99 mg/dL Creatinine: 1.0 mg/dL Ca2+: 10.2 mg/dLAlkaline phosphatase: 252 U/LLipase: 30 U/LAST: 12 U/L ALT: 10 U/LWhich of the following is associated with this patient's condition? Review Topic QID: 109612 Type & Select Correct Answer 1 Hearing loss 57% (28/49) 2 Bence Jones proteins 6% (3/49) 3 Hypercalcemia 10% (5/49) 4 Adenocarcinoma of the gallbladder 8% (4/49) 5 Obstructive jaundice 16% (8/49) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 1 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.OR.4694) 69-year-old man with no significant past medical history except for hypertension receives an X-ray of his skull (Figure A) after his car was rear-ended in a parking lot resulting in neck soreness. No fracture but what is the likely diagnosis of this incidental finding? Review Topic QID: 107772 FIGURES: A Type & Select Correct Answer 1 Bony metastases 0% (0/4) 2 Osteoarthritis 0% (0/4) 3 Paget’s disease (osteitis deformans) 100% (4/4) 4 Osteitis fibrosa cystica 0% (0/4) 5 Osteomalacia 0% (0/4) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.OR.69) A 67-year-old male presents with left hip pain. Examination reveals mild effusions in both knees, with crepitus in both patellofemoral joints. He states his hearing has worsened recently and that he feels like his hats don't fit anymore. Bone scan reveals diffuse uptake in the calvarium, right proximal femur, and left ilium. Which of the following laboratory abnormalities would be expected in this patient? Review Topic QID: 104394 Type & Select Correct Answer 1 Decreased serum alkaline phosphatase 0% (0/31) 2 Increased serum alkaline phosphatase 90% (28/31) 3 Decreased serum parathyroid hormone 0% (0/31) 4 Increased serum parathyroid hormone 3% (1/31) 5 Increased serum calcium 0% (0/31) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 2 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.OR.38) A 63-year-old male presents to his family physician with a chief complaint of right knee and hip pain as well as pain in his left upper arm. He also reports frequent headaches and notes that he has had to adjust the headband on his favorite baseball cap to a larger size after it began feeling tight earlier this year. His wife, who accompanied the patient to the visit, complains that his hearing has deteriorated noticeably over the past several months. Physical examination shows bilateral knee effusions as well as tenderness to palpation of the left shoulder as well as the right hip and lower leg. Serologic testing reveals an elevated alkaline phosphate level but normal vitamin D, calcium, and PTH. A bone scan is conducted which is demonstrated in Figure A. Which of the following is the first-line treatment of this patient's condition? Review Topic QID: 104485 FIGURES: A Type & Select Correct Answer 1 Teriparatide 6% (5/79) 2 Estrogen 0% (0/79) 3 Zoledronate 72% (57/79) 4 Dexamethasone 6% (5/79) 5 Methotrexate 13% (10/79) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M3.OR.2) A 52-year-old man presents to the emergency department after a motor vehicle collision. The patient is complaining only of left hip pain which has been ongoing for the past 6-8 months. His temperature is 98.5°F (36.9°C), blood pressure is 137/88 mm Hg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air. Examination of the left hip reveals mild crepitus, appropriate range of motion, adequate distal sensation, and palpable posterior tibial and dorsalis pedis pulses. A CT scan is ordered as seen in Figure A. Labs demonstrate an alkaline phosphatase of 876 U/L with a normal vitamin D and parathyroid hormone level (PTH). Which of the following is the most likely underlying etiology of this patient's symptoms? Review Topic QID: 102581 FIGURES: A Type & Select Correct Answer 1 Multiple myeloma 67% (2/3) 2 Osteoarthritis 0% (0/3) 3 Osteogenic sarcoma 0% (0/3) 4 Paget disease of the bone 33% (1/3) 5 Rheumatoid arthritis 0% (0/3) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 4