Cases/Musculoskeletal Health

Raised Alkaline Phosphatase and Bone Pain — Free SCA Practice Case

Man with a raised alkaline phosphatase and bone pain

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 Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Derek Ashworth

Age

68 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Booked to discuss X-ray results.

Reason for Encounter

"I'm calling about my knee X-ray results, Doctor. I've had knee pain and I want to know what's going on."

Medical Records

●PMH: None recorded.
●Medications: Ibuprofen PRN (helping).
●Allergies: NKDA.
●Colleague's note (2 days ago): 4 weeks of worsening left knee pain; wakes him at night; worse on movement; no swelling/deformity/tenderness; other joints normal. Impression: likely osteoarthritis, but night pain → X-ray to exclude underlying pathology (including tumour). Analgesia continued; safety-netted.
●Left knee X-ray report: Coarsened trabecular bone, cortical thickening, and bone expansion involving the distal femur and proximal tibia, joint space preserved; no fracture or lytic lesion; no aggressive features. Conclusion: features consistent with Paget's disease of bone; no features to suggest malignancy.

Patient Script

For the friend playing the patient role

Character Overview: You are Derek, a 68-year-old man. You have had left knee pain for four weeks — it sometimes wakes you at night and is worse on movement. Paracetamol did not help; ibuprofen gives some relief. You have never had this before. You are the sole carer for your wife, who is wheelchair-bound with a severe back problem, and your main worry is being able to keep looking after her. You suspect it is arthritis. You want to know what the X-ray showed.

Opening Sentence: "Hello Doctor. I'm ringing about my knee X-ray. I've had pain in my left knee for about a month — it wakes me at night sometimes and it's worse when I move. I've never had it before. I just want to know what it's shown."

History if Asked (Data Gathering Phase)

●The pain: "Left knee, about four weeks, worse on movement, and it wakes me at night sometimes. Paracetamol didn't touch it; ibuprofen helps a bit."
●First time: "I've never had this kind of pain before."
●Function/caring: "I'm my wife's full-time carer — she's in a wheelchair with a bad back. My worry is that if my knee gives out, I can't look after her."
●Other joints/bones: "It's just the knee. No other joints or bones bothering me."
●What he thinks: "I assumed it was arthritis — wear and tear at my age."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Derek assumes it is osteoarthritis. "I thought it'd be arthritis, just my age catching up."
●Concerns: His overriding concern is his ability to keep caring for his wife; he will also be anxious about anything sounding serious (the earlier mention of ruling out a tumour). "My real worry is being able to look after my wife. And I got a fright when they mentioned checking it wasn't a tumour."
●Expectations: He wants the X-ray explained and to know what happens next. "I want to know what the X-ray showed and what we do about it."

If Asked — Paget's Symptom, Complication, and Cause Screen

The patient answers these only when directly asked.

●If asked about swelling, deformity, or lumps over the knee/leg: "No swelling or lumps, and no obvious deformity that I've noticed."
●If asked about night pain / waking from sleep: "Yes, it does wake me sometimes at night."
●If asked about mobility / weight-bearing: "I can still walk and bear weight, but it's uncomfortable."
●If asked about other bones affected: "Just the knee area, nothing else."
●If asked about systemic symptoms (weight loss, night sweats, fever, appetite): "No weight loss, no night sweats or fevers, appetite's fine." (Reassuring against malignancy.)
●If asked about hearing changes or tinnitus: "No hearing problems or ringing in my ears." (Screens for skull involvement.)
●If asked about family history of bone disease: "Not that I know of."
●If asked about previous fractures: "No, no broken bones."

Responses to Management (The Negotiation Phase)

●If the Doctor explains it is Paget's disease, not arthritis or cancer: "So it's not arthritis? And not a tumour? What is Paget's disease?" (The tested point is explaining the unexpected result clearly and reassuringly, addressing the cancer fear.)
●If the Doctor arranges confirmatory bloods: "More blood tests? What are they for?" (The tested point is arranging ALP and related bloods to assess bone activity and exclude other causes.)
●If the Doctor discusses referral and bisphosphonates: "Do I need a specialist? And what's the treatment — you mentioned bisphosphonates?" (The tested point is specialist referral and awareness that bisphosphonates are the mainstay of treatment.)
●If the Doctor safety-nets for complications: "What should I look out for? Is it dangerous?"
●If the Doctor addresses his caring role: "The main thing is being able to care for my wife — can you help with that side of things?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Paget's Disease of Bone

●Paget's disease of bone (PDB) is a disorder of disordered bone remodelling, the second most common metabolic bone condition after osteoporosis, typically affecting people over 50 (slight male predominance).
●Many patients are asymptomatic, diagnosed incidentally via a raised alkaline phosphatase (ALP) or abnormal X-ray. Symptomatic disease causes localised bone pain, deformity, or complications depending on the site.

The Biochemical and Radiological Markers

●ALP is the characteristic biochemical marker of bone activity in Paget's (with normal calcium typically). Arrange ALP, calcium, vitamin D, LFTs, and PTH to assess turnover and exclude other causes.
●X-ray shows coarsened trabeculae, cortical thickening, and bone expansion.

Complications

●Complications include bone pain, deformity (e.g. bowed tibia, enlarged skull), pathological fractures, secondary osteoarthritis, and — with skull involvement — hearing loss/tinnitus. Osteosarcoma is a rare but serious complication (suspect with new severe pain, a mass, or systemic symptoms).

Explaining an Unexpected Result

●Explaining a result that differs from the patient's expectation (here, Paget's, not osteoarthritis) — and reassuring about cancer where a tumour was mentioned — is a key communication task.

Treatment — Specialist-Led Bisphosphonates

●Refer for confirmation and management. Bisphosphonates are the mainstay of treatment, reducing bone turnover and helping symptoms — the decision is specialist-led. Continue effective analgesia with gastroprotection as needed.

Safety-Netting

●Safety-net for fractures, loss of function, new lumps, systemic symptoms (possible osteosarcoma), and hearing changes — advising urgent review.

The Carer Dimension

●Recognise and support carers — here, a sole carer for a disabled spouse — with social prescribing and carer support, so illness does not leave the family unsupported.

Common Candidate Mistakes in This Case

●Poor result explanation: failing to explain Paget's clearly or to reassure about cancer.
●Not arranging ALP/relevant bloods: missing the biochemical assessment.
●Not referring / mishandling treatment: failing to refer, or committing to/withholding bisphosphonates rather than a specialist-led decision.
●Missing complications: not screening for or safety-netting fractures, skull involvement, or osteosarcoma.
●Ignoring his caring role: overlooking the psychosocial priority and carer support.

Free MRCGP SCA practice case for GP registrars covering Raised Alkaline Phosphatase and Bone Pain — Musculoskeletal Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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