For Student

‘What is the underlying condition, and how has it come about?’ A housebound 94-year-old woman
who has epilepsy (controlled with phenytoin) presents with falls, weakness and generalized aches
and pains. Biochemical tests reveal calcium (corrected) 1.85 mmol/L (normal range 2.05–2.60
mmol/L); phosphate 0.68 mmol/L (normal range 0.8–1.45 mmol/L); albumin 32 g/L (normal range
35–48 g/L); alkaline phosphatase (ALP) 458 U/L (normal range 30–200 U/L).

Tasks:

1. What is the likely diagnosis?

2. What factors might have precipitated this condition?
3. What signs would you look for on examination?
4. How would you treat the condition?
Student’s name
For examiner
‘What is the underlying condition, and how has it come about?’ A housebound 94-year-old woman
who has epilepsy (controlled with phenytoin) presents with falls, weakness and generalized aches
and pains. Biochemical tests reveal calcium (corrected) 1.85 mmol/L (normal range 2.05–2.60
mmol/L); phosphate 0.68 mmol/L (normal range 0.8–1.45 mmol/L); albumin 32 g/L (normal range
35–48 g/L); alkaline phosphatase (ALP) 458 U/L (normal range 30–200 U/L).

Task 1 (3.0) The likely diagnosis is osteomalacia. Lack of exposure to sunlight, poor diet if
socially isolated, poor health, and enhanced metabolism of vitamin D as a result of treatment with
phenytoin (a liver enzyme inducer) may have precipitated the condition. Diseases causing
malabsorption and chronic renal failure can also predispose to osteomalacia.
Task 2 (2.0) You need to look for proximal muscle weakness, bony tenderness (pseudo-fractures
or Looser’s zones on radiograph), and skeletal deformities such as kyphosis and bowing of the
limbs.
Task 3 (2.0) Significant hypocalcaemia can precipitate tetany with a positive Chvostek sign
(spasm of the facial muscles on tapping over the branches of the facial nerve in front of the ear)
and Trousseau’s sign (spasm of the hand and forearm muscles after compression of the forearm).
Task 4 (3.0)The blood level should be checked for 25-hydroxy-vitamin D, and vitamin D
supplements should be given either orally or intramuscularly. An adequate calcium intake should
be provided, if necessary with oral calcium supplements (1 g/day). There should be a thorough
discussion with the patient about the risks and benefits of changing to an alternative anticonvulsant
such as sodium valproate.

Final score: