A 66-year-old man comes to a community clinic after undergoing a computed tomography scan of the head at a local emergency department. He fell while stepping out of the bathtub and struck his head but did not lose consciousness. The patient sustained a small head laceration that was closed with sutures, but no other injuries were identified in the emergency department. He reports a longstanding history of normal-pressure hydrocephalus with frequent falls, but he has not followed up with his neurologist for several years. The patient is now asymptomatic with no headaches, focal weakness, or dizziness. His head computed tomography scan with bone windows is shown in the image below.
What is the best next step in management of this patient?

Question

A 66-year-old man comes to a community clinic after undergoing a computed tomography scan of the head at a local emergency department.  He fell while stepping out of the bathtub and struck his head but did not lose consciousness.  The patient sustained a small head laceration that was closed with sutures, but no other injuries were identified in the emergency department.  He reports a longstanding history of normal-pressure hydrocephalus with frequent falls, but he has not followed up with his neurologist for several years.  The patient is now asymptomatic with no headaches, focal weakness, or dizziness.  His head computed tomography scan with bone windows is shown in the image below.  
What is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0b7_9633_8f63_11c83b071742_MD0005_00 This patient likely has Paget disease of bone (PDB), a common condition in older adults that is due to increased bone turnover. His head computed tomography (CT) scan shows a thickened calvarium with an inhomogeneous bone density or "cotton wool" appearance that is typical of this condition. Most patients with PDB are asymptomatic, and diagnosis is made incidentally on radiographic findings or abnormal laboratory studies. The next step in management of this patient is to obtain calcium and alkaline phosphatase levels; patients with PDB have an elevated alkaline phosphatase and a normal calcium level. If necessary, the elevated alkaline phosphatase of PDB may be differentiated from hepatobiliary disease by measuring the bone-specific fraction. Patients with PDB should also have a radionuclide bone scan to identify other involved sites. Bisphosphonates are the mainstay of treatment for PDB as they reduce bone turnover. Most patients, including those with bone pain or involvement of high-risk locations (such as this patient with skull involvement), should be considered for treatment. (Choice A) Bone densitometry is useful in patients at risk for osteoporosis, such as women age >65, patients on long-term corticosteroid therapy, and those with a fracture suggesting bone fragility. In PDB, bone density can be low, normal, or elevated, and results do not generally change management. (Choice B) Calcium and vitamin D supplementation are appropriate if osteoporosis is suspected, but this patient's CT scan is more suggestive of PDB. (Choice C) Echocardiography and carotid ultrasonography are often used to evaluate risk for recurrent stroke in patients presenting with stroke or transient ischemic attack. This patient has no symptoms of cerebral ischemia and would not likely benefit from these tests. (Choice E) Serum protein electrophoresis is a useful screening test for patients with suspected monoclonal gammopathy, such as in multiple myeloma. Multiple myeloma usually involves bone with scattered lytic lesions or occasionally diffuse osteopenia. The thickened, sclerotic bone in this patient with PDB would not be seen in myeloma. Educational objective: Paget disease of bone is often diagnosed incidentally on a radiograph showing thickened bone with inhomogeneous density. An elevated alkaline phosphatase with normal calcium and no concurrent hepatobiliary disease may also suggest Paget disease. A radionuclide bone scan can identify additional areas of involvement; bisphosphonate medications are the usual treatment. References: Imaging Paget's disease of bone - from head to toe. (http://www.ncbi.nlm.nih.gov/pubmed/21524738)

A 66-Year-Old Man Comes to a Community Clinic After Undergoing