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) 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 DisordersEtiologySerum PhosphateSerum CalciumSerum Alkaline PhosphataseParathyroid HormoneOsteomalacia/ricketsDecreasedDecreasedIncreasedIncreasedOsteoporosisNormalNormalNormalNormalOsteopetrosisNormalNormal or decreasedNormalNormalPaget disease of the boneNormalNormalIncreasedNormalOsteitis fibrosa cysticaPrimaryhyperparathyroidism• decreasedSecondaryhyperparathyroidism• increasedPrimaryhyperparathyroidism• increasedSecondaryhyperparathyroidism• decreasedPrimary and secondary hyperparathyroidism• increasedPrimary and secondary hyperparathyroidism• increasedHypervitaminosis DIncreasedIncreasedNormalDecreased 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 Prognosis Expansion of untreated Paget lesions
QUESTIONS 1 of 8 1 2 3 4 5 6 7 8 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.OR.17.4867) 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? QID: 109612 Type & Select Correct Answer 1 Hearing loss 53% (31/59) 2 Bence Jones proteins 8% (5/59) 3 Hypercalcemia 12% (7/59) 4 Adenocarcinoma of the gallbladder 8% (5/59) 5 Obstructive jaundice 17% (10/59) M 8 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (M3.OR.15.2) 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? QID: 102581 FIGURES: A Type & Select Correct Answer 1 Multiple myeloma 12% (2/17) 2 Osteoarthritis 6% (1/17) 3 Osteogenic sarcoma 6% (1/17) 4 Paget disease of the bone 71% (12/17) 5 Rheumatoid arthritis 0% (0/17) M 10 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (M2.OR.15.69) 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? QID: 104394 Type & Select Correct Answer 1 Decreased serum alkaline phosphatase 0% (0/37) 2 Increased serum alkaline phosphatase 89% (33/37) 3 Decreased serum parathyroid hormone 0% (0/37) 4 Increased serum parathyroid hormone 3% (1/37) 5 Increased serum calcium 3% (1/37) M 6 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (M2.OR.15.38) 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? QID: 104485 FIGURES: A Type & Select Correct Answer 1 Teriparatide 6% (5/83) 2 Estrogen 0% (0/83) 3 Zoledronate 71% (59/83) 4 Dexamethasone 7% (6/83) 5 Methotrexate 13% (11/83) M 7 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (M2.OR.15.4694) 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? QID: 107772 FIGURES: A Type & Select Correct Answer 1 Bony metastases 0% (0/5) 2 Osteoarthritis 0% (0/5) 3 Paget’s disease (osteitis deformans) 100% (5/5) 4 Osteitis fibrosa cystica 0% (0/5) 5 Osteomalacia 0% (0/5) M 6 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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