Man Whose Hip X Ray Report Mentions Paget's Disease — Free SCA Practice Case
Man whose hip X ray report mentions Paget's disease
Station Timer
12:00
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
12:00
Golden MinuteFive cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Patient Profile
Full Name
Kenneth Ormerod
Age
74 years
Consultation Type
TelephoneAge
74
Situation
Telephone Consultation. Results call.
Reason for Encounter
"I had a hip X ray after a tumble. They said to ring."
Medical Records
- ●PMH: Hypertension. High cholesterol.
- ●Medications: Amlodipine 5 mg daily. Atorvastatin 20 mg at night.
- ●Allergies: NKDA.
- ●Social: Retired sub postmaster. Lives with wife. Ex smoker.
Recent Results
- ●Left hip X ray: No fracture. Coarse trabeculae, cortical thickening and expansion of left iliac wing and acetabular roof. No lytic lesion or soft tissue mass. Consistent with Paget's disease.
- ●Bloods: ALP 312 U/L (30 to 130). ALT 24. GGT 31. Adjusted calcium 2.33. eGFR 74.
Patient Script
For the friend playing the patient role
Character Overview: You are Kenneth Ormerod, a 74 year old retired sub postmaster. You ran a village post office for nearly thirty years. You live with your wife Lesley, who is 72, fit and well, and plays bowls twice a week. Your son Mark lives two hours away. You are chatty, polite and a bit formal. About three weeks ago you tripped on a kerb outside the chemist and landed on your left hip. It bruised, but you walked normally the next day. Lesley insisted on an X ray. You have felt perfectly well. You have no pain in your hip or anywhere else. You are ringing for the result and bracing yourself, because the receptionist said the doctor also wanted to discuss a blood test, which you did not know you had had. You fear this is cancer. You speak quickly when worried and go quiet when you hear something frightening.
Opening Sentence: "Hello, doctor. It's Kenneth Ormerod. I had that X ray after my fall and the receptionist said you wanted a word about the results. Is it bad news?"
History if Asked (Data Gathering Phase)
- ●The fall: "About three weeks ago. I caught my foot on a raised kerb outside the chemist and went down on my left side. I put my hand out and landed on my hip. There was a big bruise for a week but I was walking fine the next day."
- ●How he felt before and after the fall: "I wasn't dizzy or faint beforehand, I just wasn't looking where I was going. I didn't hit my head and I wasn't knocked out. I got up on my own."
- ●Hip and bone pain: "None now. The bruise has gone and the hip feels the same as the right one. I don't have any pain in my bones or joints, honestly, and nothing wakes me at night. My knees creak a bit on the stairs, that's all."
- ●Walking and function: "Walking is fine. I still walk our spaniel, Bramble, for about forty minutes every morning. I haven't noticed a limp. Lesley says I walk the same as always."
- ●Hearing and head: "I'm a bit hard of hearing in both ears, crept on over years. No headaches, no ringing."
- ●Waterworks: "I get up once at night and that's been the same for years. The flow is fine, I don't strain, and I don't dribble. I haven't seen any blood."
- ●Previous blood tests: "My blood pressure and cholesterol get checked every year, but I didn't know I'd had a blood test this time."
Ideas, Concerns, Expectations
Gating note: Kenneth does not offer any of the following unless the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for. Each part comes out only when asked.
- ●Ideas: He assumed the X ray would show a bruised bone or a crack. When he heard about the blood test he wondered what that was for. He now thinks there must be something seriously wrong. "I thought it would be a bruise or a crack. Why do bloods unless they were looking for something worse?"
- ●Concerns: He is afraid it is cancer in his bones. His older sister Margaret died of myeloma three years ago. It was found after a bone in her back broke, and she was ill for about a year afterwards. He is also worried about Lesley being left to cope. "My sister Margaret had cancer in her bones. They found it when her back broke, and then it was blood tests and X rays, just like this. Is that what I've got? I don't want to leave Lesley on her own."
- ●Expectations: He wants it explained in plain words, and wants to know whether it is cancer and what happens next. He would like Lesley to hear the plan. "Just tell me straight, doctor. Is it cancer? And what happens now?"
If Asked: Medical History and Medications
Gating note: Kenneth answers each of these plainly when the doctor asks about it.
- ●Other health problems: "My blood pressure and my cholesterol. Nothing else. No kidney trouble, no stones, no diabetes, no thyroid problem."
- ●Medicines: "Amlodipine 5 in the morning and atorvastatin 20 at night. No other tablets, no herbal remedies, nothing from the chemist."
- ●Calcium and vitamin D: "I don't take any supplements. I have milk in my tea and a bit of cheese, a yoghurt now and then. I'm outdoors with the dog most days."
- ●Allergies: "None."
- ●Previous bone treatment, scans or fractures: "I've never had a bone density scan, bone tablets or steroids. I broke my wrist as a lad falling off a bike, and that's it."
- ●Dental health: "I see the dentist twice a year. My teeth are fine."
Social History and Lifestyle Impact
- ●Home and family: Lives with Lesley in a bungalow. Mark phones on Sundays. Kenneth drives; Lesley does not.
- ●Work and activities: Walks the dog every morning, keeps an allotment and is on the bowls club committee.
- ●Smoking and alcohol: Smoked about fifteen a day until he gave up 22 years ago. Has a couple of pints at the bowls club on a Friday and a glass of wine with Sunday lunch, about eight units a week.
- ●Family history: "My dad died of a heart attack at 70. My older brother Roy had a bowed shin bone. The doctors put it down to an old football injury and he never had any treatment. My older sister Margaret died of myeloma three years ago. They found it after a bone in her back broke. Lesley's side are all healthy."
- ●Availability to be seen: Can come to the surgery any morning, and Lesley can come with him. He would like her to hear what is said.
If Asked: Associated Symptoms
Gating note: Kenneth answers these only when asked. Every one is negative unless stated.
- ●If asked about weight loss, night sweats, fevers or loss of appetite: "No, none of that."
- ●If asked about back pain, rib pain or pain in any other bone: "No. My back is good for my age."
- ●If asked about passing blood, urinary symptoms, difficulty starting the stream or testicular lumps: "No. Same as I told you, once at night and that's all."
- ●If asked about thirst, constipation, tummy pain, kidney stones or feeling muddled: "No to all of those."
- ●If asked about a bowed leg, changes in his height or hat size, or a lump on any bone: "Not that I've noticed. Lesley says I've got a bit shorter, but I think that's just the stoop of age."
- ●If asked about cancer in the past: "Never."
Responses to Management (The Negotiation Phase)
- ●If the doctor says it is not cancer, or explains what the finding means:
- ●Reaction: Wary and relieved at the same time. "So it isn't cancer? How can you be sure when Margaret had it in her bones?" If told the X ray looks like a bone condition where the bone renews itself too quickly, which is common in older people and very rarely becomes cancer: "So it's not like Margaret's? Oh, thank goodness. Why on earth did I have this, then?"
- ●If the doctor says he will arrange more tests:
- ●Reaction: Asks what they involve. "What sort of scan? Do I have to stay in?" He accepts when told it is a visit for a scan and perhaps more bloods. "Is it a hospital job? Lesley doesn't drive, so I'll need to get her there too."
- ●If the doctor asks why he is not being given treatment now, or explains that treatment is for people with symptoms or risky sites:
- ●Reaction: Puzzled. "If it's there, why not treat it straight away? Wouldn't it be better to stop it early?" If told that tablets or a drip are kept for pain or for places where trouble could follow, and that the specialist decides: "I see. So someone who knows this will look at the pictures properly. That makes me feel better. What sort of treatment is it?"
- ●If the doctor says he needs to see a specialist or is referring him:
- ●Reaction: Anxious. "A specialist? That sounds serious. Is it urgent?" If told it is not an emergency but a bone clinic to confirm the extent and decide on treatment, he settles. "Fine. How long will it be? Will they write to me or ring?"
- ●If the doctor asks about the future, or explains that it can weaken the bone or cause problems later:
- ●Reaction: Wants practical answers. "Will it break my hip? Will I end up in a wheelchair? Should I stop walking the dog?" He asks whether he should be looking after the bone in any way. If told about keeping active, getting enough calcium and sunlight, and watching for falls, he says: "Right. I'll keep walking Bramble then. I don't take any vitamins, should I?"
- ●If the doctor discusses relatives, or gives safety netting (he asks about family at the end if the doctor has not):
- ●Reaction: Thinks of the family. "Does this run in families? Roy had a bowed shin. Should he be checked? What about Mark?" If told that relatives do not routinely need testing but should mention it if they have persistent bone pain: "I'll tell Roy. He won't want a fuss, mind." If safety netting is vague, such as "come back if it gets worse": "Worse how? What exactly should I be watching for, and who do I ring?" He repeats back specific advice, such as new bone pain that does not settle, a new lump or swelling, a fall or sudden pain in the hip, or new hearing change.
Mark Scheme
Domain 1: Data Gathering and Diagnosis
0 / 14 indicators checked+0−0
Positive (0/7)
Negative (0/7)
Domain 2: Clinical Management and Medical Complexity
0 / 20 indicators checked+0−0
Positive (0/10)
Negative (0/10)
Domain 3: Relating to Others
0 / 14 indicators checked+0−0
Positive (0/7)
Negative (0/7)
Clinical Learning Points
1
The Core Dilemma and the Model Plan
- ●Kenneth is a 74 year old man with no bone pain, a hip X ray taken after a trip that shows changes typical of Paget's disease of bone in the left hemipelvis, and an ALP (alkaline phosphatase) of 312 U/L with normal ALT (alanine aminotransferase), GGT (gamma glutamyl transferase) and calcium. He fears cancer because his older sister died of myeloma, which was found after a spinal fracture. The station tests explaining an incidental finding honestly, deciding who treats it and when, and not over or under investigating.
- ●The model plan has six parts. Interpret the results as a bone source of ALP. Keep other causes in mind and settle them with the history, a bone profile and vitamin D. Recognise that treatment is a specialist decision and is not started for a pain free man in primary care. Arrange a non urgent specialist assessment, with an isotope bone scan either requested first or left to the specialist. Correct any calcium or vitamin D deficiency. Give specific safety netting and close the loop on who does what.
- ●Acceptable alternatives that also pass: asking for specialist advice and agreeing a documented ALP recheck plan, requesting specialist advice (advice and guidance) instead of a formal referral, asking the specialist to arrange the bone scan, requesting the bone scan first and sending the result with the referral, or checking the bloods and seeing him in person before referring. A face to face appointment is welcome but not required. What does not pass is dismissing cancer on the phone, urgent cancer pathway referral with no red flags, or starting a bisphosphonate in primary care.
2
What Paget's Disease of Bone Is
- ●Paget's disease is a focal disorder of bone remodelling. Osteoclasts, the cells that absorb bone, become overactive, and the osteoblasts that follow lay down new bone quickly and in a disorganised way, so the bone becomes larger, denser in places and weaker. It is fairly common in older people in the UK and rare under 50 (NHS).
- ●The pelvis, spine, femur, skull and tibia are the usual sites. It can affect one bone or several. Most people have no symptoms, and the diagnosis is made by chance from an X ray or a raised ALP, as here.
- ●There is no cure, but treatment can control the disease. A family history raises the risk, and variants in the SQSTM1 gene are found in 40 to 50% of familial cases (Ralston and colleagues, 2019), but genetic profiling is listed there as a research question, not routine care. Kenneth's brother's bowed shin may have been the same condition, but that cannot be known on the telephone.
3
Interpreting the X Ray and the Blood Tests
- ●The X ray features of coarse trabeculae, thickened cortex and bone expansion are typical of Paget's disease. The absence of lytic lesions or a soft tissue mass is reassuring.
- ●A raised total ALP with normal liver enzymes and GGT points to bone. ALP can be normal in disease limited to one bone, so a normal ALP does not exclude it, but a raised value in active disease is a useful marker of activity and later response to treatment. Here it is about 2.4 times the upper limit of normal.
- ●Check a bone profile (adjusted calcium, phosphate, ALP) and vitamin D. Calcium is normally normal in Paget's disease. Raised calcium suggests another cause or immobilisation, and a low value or low vitamin D matters before treatment. An isotope bone scan shows how many bones are affected and where, and the specialist usually directs follow up X rays from it.
4
Other Causes of a Raised ALP and Dense Bone
- ●Sclerotic bone metastases can raise ALP and make bone look dense. The expansion of bone and coarse trabecular pattern favour Paget's disease, and an asymptomatic man with no weight loss, no bone pain and no new symptoms is unlikely to have metastases, but the possibility belongs in the differential and the history is how it is settled.
- ●Vitamin D deficiency with osteomalacia raises ALP and usually lowers or borderline lowers calcium. Liver and biliary disease raise ALP with GGT and ALT, which are normal here. Myeloma, the cancer his sister had, typically shows lytic lesions with a normal ALP, and is often accompanied by bone pain, tiredness, raised calcium, anaemia or kidney impairment. Kenneth has no lytic lesion on the X ray, no pain, and normal calcium and kidney function, so this is not the picture. His sister's illness explains his fear, but it does not make Paget's disease more likely, and Paget's disease is not a form of cancer.
- ●No test for myeloma is needed. NICE NG12 advises blood tests for myeloma in people aged 60 and over with persistent bone pain, particularly back pain, or an unexplained fracture, and Kenneth has neither, with no lytic lesion and normal calcium and kidney function. Relatives of people with myeloma are not routinely tested when they have no symptoms, so the answer to his fear is a clear explanation rather than a test.
5
Deciding Whether to Treat
- ●Treatment in Paget's disease aims to reduce pain and prevent complications, using a bisphosphonate to slow the turnover of bone. Pain thought to come from Paget's disease is the clearest reason to treat. For asymptomatic people with raised bone turnover, the 2019 Ralston guideline says only that a bisphosphonate may be considered and that the clinical benefit is uncertain, with no trial showing it prevents complications; it recommends bisphosphonates for bone pain and sets the goal as controlling pain rather than normalising ALP. Specialists may still treat active disease next to a joint or at the skull base, but that is clinical judgement, which is why a specialist decides.
- ●In this case the acetabular roof sits beside the hip joint, which is a reason for specialist assessment rather than watchful waiting alone. The BNF lists zoledronic acid for Paget's disease as specialist use only: 5 mg by intravenous infusion for one dose, with at least 500 mg elemental calcium twice daily with vitamin D for at least 10 days afterwards. Oral risedronate 30 mg daily for two months is an alternative the specialist may choose. Avoid zoledronic acid if creatinine clearance is below 35 mL/minute, and correct low calcium and vitamin D first. Kenneth's eGFR of 74 is no barrier.
6
Referral and Follow Up
- ●Refer non urgently to rheumatology, endocrinology or a metabolic bone service, or seek advice and guidance first. Include the X ray report, the ALP, calcium, liver and renal results, and the absence of pain. An urgent suspected cancer pathway referral is not needed without red flags.
- ●Urgent assessment is needed for new severe or rapidly progressing pain or swelling over a pagetic bone (osteosarcoma is a rare complication, affecting about 0.3% of patients, or roughly 3 in 1,000, in the Ralston guideline), a pathological fracture, new neurological symptoms from nerve or spinal compression, or hypercalcaemia.
- ●Close the loop. Say who arranges what, how long to wait, and what the practice will do if no appointment arrives. Offer a review with his wife present.
7
Calcium, Vitamin D, Falls and Fracture Risk
- ●Check vitamin D and calcium and make sure they are replete, because bisphosphonates can cause hypocalcaemia in deficiency. Encourage dietary calcium and sensible sun exposure, and give a vitamin D supplement if the level is low.
- ●His fall was a mechanical trip with no loss of consciousness, no head injury and no dizziness, and he walked the next day, so a hip fracture is unlikely. Pagetic bone is more likely to break, so falls prevention and keeping active are sensible.
8
Communicating the Result and Safety Netting
- ●Find out what he knows, since he did not know he had had a blood test. Give the result early in plain words: the bone is renewing itself too fast and growing larger and weaker, it is common in older people, usually found by chance, and cancer is a very rare complication.
- ●Explain why no tablets are started now, what treatment exists if needed, and why a specialist will decide. Explain that the guideline makes no recommendation to test relatives, but that they should mention persistent bone pain or a change in shape.
- ●Specific safety netting: new or persistent bone pain; sudden severe pain, swelling or a lump over the hip or pelvis; another fall with inability to bear weight (999 or emergency department); new hearing loss or headaches; new leg weakness, numbness or trouble controlling bladder or bowel (urgent same day assessment).
9
Common Mistakes in This Station
- ●Telling him on the phone that it is definitely not cancer, or leaving the cancer fear unaddressed because the report says no malignant features.
- ●Starting a bisphosphonate or painkillers in primary care for a pain free man, or saying nothing will ever be needed.
- ●Referring as a suspected cancer without red flags, or arranging only repeat blood tests with no specialist advice and no review plan.
- ●Ignoring the calcium and vitamin D result, or giving high dose calcium without checking.
- ●Missing the family question, or advising that all relatives be tested urgently.
- ●Safety netting with "come back if it gets worse" and no named symptoms.
Mapped to the RCGP curriculum topic: Musculoskeletal Health.
← Back to Free SCA Practice Cases