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Elderly Man With Pain in His Thigh

Elderly Man With Pain in His Thigh

A 77-year-old man complains of deep, aching pain of several months' duration in his left thigh that is exacerbated by both standing and walking. The pain is not relieved by lying down and frequently bothers him at night. NSAIDs and acetaminophen provide moderate but temporary relief. He denies any significant trauma to the area.

HISTORY

His health is otherwise reasonably good. He has moderate hypertension that is well controlled by an angiotensin-converting enzyme inhibitor and a diuretic. He also has mild chronic obstructive pulmonary disease that resulted from smoking (he quit 10 years ago); this is managed with a combination b2-agonist/corticosteroid inhaler. It has been more than 5 years since he was last hospitalized. His weight is appropriate for his height and age, and his appetite is good; he reports no change in either. He has had nocturia twice nightly for several years but denies dysuria, hematuria, and other genitourinary symptoms. He is a retired mailman and does not use alcohol or illicit drugs.

PHYSICAL EXAMINATION

Blood pressure is 120/75 mm Hg; other vital signs are also normal. No enlarged lymph nodes are noted. Breath sounds are decreased, but no rales or wheezes are audible. Heart rate is 88 beats per minute and regular, without murmurs or gallops. No organomegaly or abdominal masses are detected. The left thigh is warm anteriorly over the femur, and deep palpation of the bone elicits tenderness but no evidence of a discrete mass.

LABORATORY AND IMAGING STUDIES

Results of a complete blood cell count and chemistry profile are normal. The patient's uric acid level is normal, but his alkaline phosphatase level is 492 U/L (normal, less than 125 U/L); transaminase levels are normal. Plain radiographs of the left femur reveal areas of thickened cortex and mottling (osteosclerosis and osteopenia). No discrete lytic lesions are seen, and the remainder of the skeleton shows no abnormalities. A bone scan reveals enhanced radionucleotide uptake in the left femur.

Which of the following statements about the patient's condition is true?

A. MRI and CT are required to make a definitive diagnosis.
B. Hypocalcemia is a frequent metabolic complication of the disease.
C. Neoplastic transformation is a rare but deadly complication.
D. If therapy is required, salmon calcitonin by subcutaneous injection is the pharmacological agent of choice.

(Answer on next page)

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