Station 88

Benjamin Turner

Age: 68 year old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis

  • Stary by acknowledging previous consultation and imaging: “I can see you saw my colleague recently because of knee pain, and you were sent for an X-ray. Am I right? Could you tell me in your own words how the pain is now, has it been getting better, worse, or staying the same?”
  • Ask about any swelling, stiffness, or any noticeable lumps or bumps over the affected knee
  • Ask specifically about night pain or whether the symptoms wake the patient from sleep
  • Ask about current mobility, whether the patient is able to walk, bear weight, or if it limits his daily movement
  • Ask if any other joints or bones are affected or painful
  • Ask about systemic symptoms such as fever, night sweats, unexplained weight loss, or loss of appetite to rule out underlying malignancy (e.g. osteosarcoma as a rare complication of Paget’s disease)
  • Ask about hearing changes, such as hearing loss or tinnitus, which may indicate skull involvement in Paget’s disease.
  • Ask about family history fo any bone disease. 
  • Ask about social history, including occupation and living arrangements, and how this problem has impacted daily activities or caregiving responsibilities at home. 
  • Acknowledge the patient’s role as a sole carer for his wife and explore how his knee pain is affecting his ability to provide care
  • Explain the X-ray findings are suggestive of Paget’s disease of bone

Example of explanation to patient​

Thank you for coming in today, Benjamin. I have reviewed your X-ray, and I can reassure you that it does not show osteoarthritis, which I know you were worried about. Instead, it shows changes that the cause of your pain is a condition called Paget’s disease of bone.

Is this something you have heard about before? 

Paget’s disease is a condition that affects the normal cycle of bone renewal. This leads to the pain that you are experiencing. It is not exactly clear what causes Paget’s disease, but we do know that people are more likely to get it if it runs in the family.

I can see that one of your main worries is how this might affect your ability to care for your wife, especially since you are her main support at home. That is completely understandable, and you are doing an incredible job looking after her. While we work on managing your knee pain and getting the right treatment started, I would like to help make sure you are not trying to cope alone. I can arrange for our social prescriber to explore what extra help might be available for you both at home, even if it is just temporary support while things settle. Would that be helpful for you?

Management

Management

  • Offer blood tests including serum total alkaline phosphatase (ALP), liver function tests, calcium, vitamin D, and parathyroid hormone (PTH) to assess metabolic bone activity and rule out other causes
  • Offer a referral to rheumatology for further evaluation, diagnosis confirmation, and consideration of treatment
  • Advise the patient that the specialist may recommend bisphosphonate therapy, which is commonly used to reduce bone turnover and help manage symptoms
  • As ibuprofen is providing some relief, advise the patient that he can continue using it, but offer a proton pump inhibitor (PPI) to protect the gastrointestinal tract, particularly given his age. 
  • Offer a referral to a social prescriber to discuss community support services and any potential eligibility for carer benefits or practical assistance with care for his wife. 
  • Provide clear safety netting and advise the patient about the risk of fractures and the rare but serious risk of osteosarcoma associated with Paget’s disease
  • Instruct the patient to seek urgent medical review if he develops sudden or worsening bone pain, becomes unable to walk or use a limb, or notices any new lumps, swelling, or systemic symptoms such as weight loss or fever
  • Advise the patient to report any hearing loss or tinnitus, as this may indicate involvement of the skull in Paget’s disease

Learning point from this station: ​

Paget’s disease of bone (PDB) is the second most common metabolic bone condition after osteoporosis, typically affecting individuals over the age of 50, with a slight male predominance.

Most patients are asymptomatic and diagnosed incidentally through elevated alkaline phosphatase (ALP) on routine blood tests or abnormal X-ray findings.

Symptomatic patients typically present with pain localised to the affected bone, along with skeletal deformities, swelling, or neurological symptoms depending on the location (e.g. deafness or tinnitus if the skull is involved).  

Common complications include:

  • Bone pain
  • Bone deformities (e.g. bowed tibia, enlarged skull, frontal bossing)
  • Pathological fractures
  • Osteoarthritis near affected joints
  • Hearing loss and tinnitus due to skull involvement 
Further reading