Paget’s disease

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 02/04/2015

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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

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