Paget’s disease

229 Paget’s disease



Instruction


Examine this patient’s face.


Examine this patient’s legs.



Salient features



History




• Ask the patient whether there is an increase in hat size


• Bone pain


• Joint pain (from osteoarthritis secondary to bone disease)


• Painless bowing of the bone can be the first symptom


• Hearing loss


• Fractures with minimal trauma


• Nerve entrapment syndromes including paraparesis and radioculopathy when the spine is affected.



Examination




• Face:


• Comment on the hearing aid, if any; test hearing and determine whether the deafness is a conduction defect (from involvement of the ossicle) or neural (from compression of the eighth nerve)

• Typical appearance of the skull and increased skull diameter (>55 cm is abnormal)

• Tell the examiner that you would like to examine the fundus for optic atrophy or angioid streaks.

• Neck:


• Look for platybasia

• Raised JVP (cardiac failure in Paget’s disease is caused by hyperdynamic circulation).

• Spine:


• Deformity of the spine: kyphosis

• Auscultate over the vertebral bodies for bruits

• In up to one-third of patients the third and fourth lumbar vertebrae are involved, and in 20% the lower thoracic vertebrae are involved.

• Legs:


• Comment on the anterior bowing of the tibia (Fig. 229.1D) and the lateral bowing of the femur

• Feel the bone for warmth

• Tell the examiner that you would like to examine the joints for osteoarthritis (limitation of hip movement, in particular abduction, and fixed flexion deformity of the knees).

• Proceed by tell the examiner that you would like to:


• Do a urine analysis (high incidence of renal stones)

• Measure the patient’s height (for serial follow-up)

• Compare the patient’s appearance with a previous photograph

• Ask the patient whether there is an increase in hat size.

image

Fig. 229.1 (A) Radiograph of tibia, showing bone deformity, expansion and alternating areas of osteosclerosis and osteolysis with a pseudofracture on the convex aspect of the tibia. (B) Radionuclide scan showing increased tracer uptake in affected femur. (C) Pathological fracture through affected femur. (D) Severe tibia deformity.


(With permission from Ralston et al. 2008.)

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Dec 4, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Paget’s disease

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