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alk phos q

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virgola82
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07/05/07 - 03:35 PM

A 56 yo man is admitted to the hospital for elective cardiac bypass surgery. as part of his pre-op evaluation you note an elevated alk phos. The other liver function tests are normal. Serum Ca and Phosphate are within normal limits. The patient denies any history of bone pain and the physical exam is normal. What is the next step in the management of this patient?

A. Obtain a radiologic bone survey

B. Order a nuclear bone scan

C. Begin risderonate orally

D. Order a 24 h urine test for hydroxiproline

E. Begin intranasal calcitonin

young_doc
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07/05/07 - 03:42 PM

Patient probably has Paget's disease --> D.

Urinary hydroxyproline indicates bone resorption/formation.

No treatment required in Asymptomatic Paget's...so no bisphosphonates or Calcitonin.

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ssrpk
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07/05/07 - 03:53 PM

agree with D

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usmlestud
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07/05/07 - 04:48 PM

virgola82
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07/05/07 - 05:27 PM

That's what I picked too... but according to the explanation it's not the best initial test. Urinary hydroxyproline is a very sensitive test for active disease but should be done only after another action among those listed

usmlestud
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07/05/07 - 05:30 PM

is it B

dr in trouble
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07/05/07 - 05:46 PM

I choose B too.

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young_doc
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07/05/07 - 06:13 PM

After looking into it, you're absolutely right!... a Radionuclide bone scan is the most sensitive test for Paget's!

Thanks for the Questions smiling face

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virgola82
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07/06/07 - 09:41 AM

I am sorry again guys, the most sensitive tests for paget are radionuclide scan (1st) followed by urinary hydrxyproline (2nd most sensitive) but in this case they are not the best next step. Either urinary hydroxyproline or radionuclide scan should be done only after a radiologic bone survey that even though less sensisitive could allow a fast and cheap diagnosis. If the radiologic survey is negative than you do radionuclide scan or hydroxyproline. At least this is what is written here (Fischer's book). Treatment should not be started until the pt become symptomatic or there is cranial involvement. The best initial therapy is with biphosphonates, calcitonin is not used anymore.

ssrpk
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07/06/07 - 09:45 AM

#10

okay makes sense but what if the patient has all the classical symptoms of paget's disease....wht then xray first or bone scan??

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virgola82
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07/06/07 - 01:57 PM

#11

according to dr fischer always xray first, I tried check on UTD but it doesn't mention about what's better to be done first

ssrpk
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07/06/07 - 05:52 PM

#12

okay will remeber that,
do me a favor plz, check out the dr.fischer's notes on bone metastasis and list the tests in the order they should be done.
thanks

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