View source for WBR0237

 {{WBRQuestion
|QuestionAuthor= {{M.P}}
|ExamType=USMLE Step 3
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|MainCategory=Primary Care Office
|MainCategory=Primary Care Office
|SubCategory=Musculoskeletal/Rheumatology
|Prompt=A 60 year old male come for routine health check up.  He is found to elevated alkaline phosphate levels.  His serum calcium and phosphorus levels are normal.  He denies any bone pain or bone deformity.  His liver function tests are normal.  Bone scan reveal increased uptake in the left knee and his urinary hydroxyl proline levels are increased.  A diagnosis of Paget’s disease is made.  What is the most appropriate line of management in this patient?


|Explanation=[[Paget’s disease]] is characterized by an increse rate of bone turnover.  Causes both excessive resorption and excessive formation of bone, leading to a “mosaic” lamellar bone pattern.  Suspected to be due to latent viral infection in genetically susceptible individuals.  Found in roughly 4% of men and women > 40 years of age, and associated with 1° [[hyperparathyroidism]] in up to one-fifth of patients.  Usually asymptomatic, but may present with aching bone or joint pain, headaches, skull deformities, fractures, or nerve entrapment (leads to loss of hearing in 30–40% of cases).  Treatment in Paget’s disease is done only for the following.

1.	Bone pain
2.	[[Hypercalcemia]] of immobilization
3.	High output [[cardiac failure]]
4.	Neurological symptoms
5.	Involvement of weight bearing joints to prevent deformities
6.	Preparation for orthopaedic surgery.
|AnswerA=Treatment with calcium and vitamin D
|AnswerAExp='''Incorrect''' : [[Calcium]] and [[vitamin D]] has no effect.  However it is safe to measure vitamin D levels, as their deficiency may present with increased bone turnover.
|AnswerB=Treatment with bisphosphonates
|AnswerBExp='''Correct''' : [[Bisphosphonates]] are the treatment of choice for Paget’s disease.  Their early effect is decreased bone resorption.  Their effect persist for months to years after treatment making it superior to calcitonin.
|AnswerC=No treatment at this time
|AnswerCExp='''Incorrect''' : No treatment is required in asymptomatic patients.  However involvement of weight bearing joints mandates to start treatment to prevent future deformities.
|AnswerD=Treatment with calcitonin
|AnswerDExp='''Incorrect''' : [[Calcitonin]] has similar action to bisphosphonates by reducing bone resorption, however it is weak when compared to bisphosphonates.
|AnswerE=Treatment with NSAID’s and acetaminophen
|AnswerEExp='''Incorrect''' : [[NSAID’s]] and [[acetaminophen]] is helpful in reducing pain due to arthritis.
|RightAnswer=B
|Approved=Yes
}}