153) A 68 year old man presents to the clinic for progressive right hip pain. He has a history of hearing impairment. He reports pain in the right hip when walking more than 1 block and also, has difficulty putting shoes on his right foot. On examination, the range of motion is significantly limited in the right hip. An X-ray of the right hip reveals significant loss of cartilage, subchondral sclerosis and sub-chondral cysts. X-ray also reveals pagetoid changes in the right liac wing and right femoral neck. Serum alkaline phosphatase level is normal. The most appropriate initial step in managing this patient is:
A) Bisphosphanates
B) Acetaminophen, Quadriceps strtengthening and Tai-Chi
C) Bisphosphanates and Acetaminoiphen
D) Calcitonin
E) Oral prednisone
Archer USMLE Step 3 Blog 
bbbbbbbbb,osteoarthritis
C i think.. guess u treat both pagets and osteo..
IN PAGETS DISEASE ALKALINE PHOSPHATASE LEVELS ARE INCREASED……ANSWER B
B) Acetaminophen, Quadriceps strtengthening and Tai-Chi
B
C. Give bispho and tylenol for pain since pain brought him to clinic to begin with. Tai-Chi-any high level evidence that it help with OA?
I think the correct answer is D. He has pagetoid changes on femoral neck. Bispho will take time to work not like calcitonin.
?B or ?C.., hearing loss, bone pain, pagetoid changes in x ray and OA hip are features of paget’s disease.In patients with monostotic disease or local disease, the total alkaline phosphatase level may be normal. Consequently, a normal alkaline phosphatase level does not exclude the disorder. In this scenario, a BSAP level should be ordered. In patients with abnormal liver function or other causes of elevated alkaline phosphatase activity not due to bone, BSAP is a reasonable means of assessing Paget disease activity.
BSAP had the highest diagnostic sensitivity (84%) in a comparative study of different markers of bone turnover in patients with Paget disease. The next most sensitive marker was total alkaline phosphatase, which had a sensitivity of 74%
http://emedicine.medscape.com/article/334607-workup#aw2aab6b5b2
c hearing loss.pagetoid changes in bearing bones.even if alp normal
My answer is Option C.
Diagnosis: Osteoarthritis of Right Hip Joint secondary to Paget’s disease.
Reason: I say this because there is X-ray evidence of Paget’s disease in the question and X-ray evidence of Osteoarthritis in adjacent joint. AND Osteoarthritis does not cause Paget’s disease. (joke)
Why do I say secondary osteoarthritis and not primary Osteoarthritis coexisting with Paget’s disease?
I would prefer to say co-existing if the destruction of bone from Paget’s disease was found in a remote bone, not the adjacent hip and the adjacent femoral neck. If there was Paget’s disease of the skull bones and osteoarthritis of the knee, I would not say secondary osteoarthritis.
Pathophysiology: Paget’s disease affects bones in a locally destructive fashion and can cause Osteoarthritis in the nearby joints. In this case, the right femoral neck and the right iliac bone are severely affected judging by the normal alkaline phosphatase. A normal alkaline phosphatase can be found in in burnt out sclerotic bones provided there is X-ray evidence of Paget’s disease (like in this patient). Whenever there is bone remodelling, bone resorption or formation, alkaline phosphatase is elevated, many atimes, even asymptomatically in Paget’s disease. But in burnt out (severe disease), sclerotic tissue replace bone tisssue and this tissue does not produce alkaline phosphatase. So bone specific Alkaline phosphatase level becomes normal. Nevertheless, the damage is severe and the adjacent joints bear the brunt of soft bones. Sclerotic bones are weak and soft compared to calcified bones. Abnormal bone to bone alignment occurs in adjacent joints leading to joint trauma and osteoarthritis.
Most appropriate initial step: treat Paget’s disease and treat osteoathritis.
Why treat Paget’s disease that has normal alkaline phosphatase? Is it not like asymptomatic “quiescent” Paget’s disease. It’s not the bone that is causing the pain.
Answer: We are not sure this is quiescent disease. In a study 15% of symptomatic Paget’s disease patients had normal alkaline phosphatase: http://www.ncbi.nlm.nih.gov/pubmed/14561571
We would need to do bone scan and urine test to check for markers of bone resorption. This would indicate active or dormant disease and it will also be a marker of successful treatment if these are used to monitor treatment.
Biphosphonate will inhibit resorption and slow the disease process of Paget’s disease.
Why did I reject exercises and Tai-chi in osteoarthritis?
This is moderate stage 3 to stage 4 osteoarthritis. The cartilage is torn and significantly damaged, any movement will cause pain. I will not recommend exercises and movements at this stage. If x-ray showed only bone spurs only, even significant bone spurs without cartilage damage, I may have advocated exercises too. In this case, exercises will worsen his symptoms.
References:
http://orthoinfo.aaos.org/topic.cfm?topic=a00076
http://en.wikipedia.org/wiki/Paget's_disease_of_bone
http://www.niams.nih.gov/Health_Info/Bone/Pagets/pagets_osteoarthritis.asp
http://www.ncbi.nlm.nih.gov/pubmed/14561571
http://www.healthline.com/health/osteoarthritis-stages-of-oa-of-the-knee
http://www.ncbi.nlm.nih.gov/pubmed/912993
http://cjasn.asnjournals.org/content/3/Supplement_3/S131.full
I really enjoy reading your thought process. It’s so logical, methodological and easy to follow. Thank you for all your contributions, Adnan!
Thank you Nasism. I appreciate your great compliment.
Dude..from where the hell do u have this much of knowledge…wow..simply amazing…r u a doctor or still tryin for a residency…..
Wow! I feel like a superstar. Thank you Scorpio. I really appreciate your great compliment. You are really generous in your compliment but I do not deserve any more notoriety over knowledge than yourself. But thank you for making me feel so special. It’s that one moment that people are always waiting for.
As far as what I do, here goes (I hope you pick the humor in it). I am a cardio thoracic surgeon and I operate on chickens and vegetables in my hometown. Sometimes I speak up like Dr Oz but I don’t know why the television will not hire my show.
I love medicine passionately but the industry is dominated by greater narcissists than myself all the time. What can I do? I feel smothered sometimes. And so I escape and find my solace in a wonderland created by Dr Red on Dr Archer Red’s USMLE Step 3 blog. I loved it so much here and I find myself here in my free time, a place where doctors gather to discuss patients just like the 1800s when I ended up operating on Frankenstein. Yes! It was me but they won’t tell you that!!! HaA!
Scorpio, I hope you had fun reading through my response. If not, I will try again next time.
Now here’s the oracle speaking to you so listen carefully. ‘ Scorpio…, Scorpio…, remember, you are going to excel in life and build your utopia land one day if you start working early on your dreams, be passionate about it, be persistent about it, and if you remember to pay me my consultation fee, and be nice to little children.’
Remain blessed,
Signed
Father Gregor Mendel(I’m sorry father if you heard that),
Father Crito on behalf of Father Socrates
Enjoy the rest of your day Scorpio. Danke.
I hereby anoint all you bloggers who care to read my post and who religiously visit Dr Archer’s USMLE Step 3 blog as knights in the guild of knowledge, you are hereby knighted as plastic surgeons and gastroenterologist, radiologists and anesthesiologist, dermatologists and endocrinologist, neurologists and brain surgeons. Don’t let any narcisistic take your dream away from you.
nice one Adnan. bit of a strange unit aren’t ye!! good man your self. : )
stupid you are
c