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PATIENT CASE Patient’s Chief Complaints “I’ve had aback affliction now for added than 5 weeks and I can’t angle it anymore. I’ve approved extra-strength ibuprofen, naproxen, and acetaminophen, and I’ve visited a chiropractor, but I don’t get any abiding relief.” History of Present Illness Mrs. I.A. is a actual affable 63-year-old white woman of slight adeptness who has been referred to an orthopedic specialist by her PCP. She has been experiencing insidious aback affliction for 5–6 weeks. OTC analgesics accommodate acting relief, but the affliction is contrarily connected and aggravated by activity. She denies any accessible astute abrasion to her back, although she letters that she had a case of the flu with a abiding and astringent ahem about one ages ago. She additionally letters a vertebral breach about bristles years ago. The accommodating has been an ardent agriculturalist for abounding years. Afterward the afterlife of her bedmate 18 months ago, she has connected to alive in her abode and do all the domiciliary chores. Aback her aback affliction began, she has been bound in her adeptness to do her domiciliary affairs and gardening.

Past Medical History The accommodating entered accustomed menopause at 52 years and has never acclimated hormone backup therapy. Currently, she has balmy hot flashes and vaginal dryness. At age 58, she suffered a vertebral breach at T10 by artlessly accustomed a arcade bag. DEXA scans conducted at that time appear the access of osteoporosis. Her cartilage accumulation body T-scores at that time were: −3.33 lumbar spine, −2.24 adapted femoral neck, and −2.44 adapted radius. These scans represented a 6.1%, 6.9%, and 6.2% abatement in cartilage accumulation body in the antecedent 19 months in the lumbar spine, adapted femoral neck, and adapted radius, respectively. Her serum calcium absorption was low-normal at 8.5 mg/dL and serum acrid phosphatase akin was moderately added at 290 IU/L. She was assigned alendronate and a calcium supplement daily. The accommodating was diagnosed with a access ataxia at age 22 years and is currently able-bodied controlled with phenytoin. She has had asthma aback childhood. Her accepted asthma medications accommodate a bronchodilator that she uses aback needed, a circadian steroid inhaler, and an articulate corticosteroid that she uses about four times per year for 3–6 weeks aback affection worsen. She additionally takes a circadian multivitamin book and has 1–2 dairy servings every day. She has noticed a slight abridgement in acme in contempo years, but denies any cogent changes in weight. She had an appendectomy at 11 years of age.

Patient Case Question 1. Afterward her vertebral breach at T10, the accommodating was assigned alendronate and calcium. Which added pharmacotherapeutic abettor should accept been prescribed? Patient Case Question 2. At the time of her antecedent DEXA scans 19 months ago, was osteoporosis present in the spine, femur, and radius? Patient Case Question 3. Based on the advice provided so far, which blazon or types of osteoporosis does this accommodating have?

Family History The accommodating has a absolute ancestors history of osteoporosis. Her earlier sister has accomplished a hip breach and her benevolent aunt was diagnosed with an osteoporosis-related wrist breach afterward a fall. Her mother was diagnosed with breast blight at age 56, but died from lung blight at age 69. She additionally suffered from aerial claret burden and “high claret sugar.” Her ancestor died at age 54 from AMI. Her brother (age 65) has HTN and aerial cholesterol, and her adolescent sister (age 57) has no accepted medical problems. Social History The accommodating smokes four cigarettes a day (down from 1 ½ ppd eight years ago) and drinks one bottle of wine daily. Her capital sources of comestible calcium are milk with her breakfast atom and “some” cheese about three times a week. The accommodating is abandoned and was affiliated for 39 years until the afterlife of her bedmate 1 ½ years ago. She has one son who is healthy. She had a abortion at age 19. She does best of her affable and “watches what she eats.” She denies non-compliance with her medications. She gets actual little weight-bearing exercise. She uses SPF 30 sunscreen to assure herself from sunburn and bark blight every time that she spends added than 15 account in the sun. Review of Systems The accommodating denies any aberrant bleeding, weakness, aback spasms, conciseness of breath, chest pain, fever, chills, calefaction or algid intolerance, and changes in her hair, skin, and nails. She letters vaginal dryness, casual hot flashes and night sweats “maybe already every 6 months.” Medications Alendronate 10 mg po QD Calcium carbonate 1.25 g (500 mg calcium) po BID Multivitamin book po QD Phenytoin 100 mg po TID Albuterol MDI 2 puffs BID PRN Triamcinolone MDI 2 puffs QID Prednisolone 5 mg po BID PRN

Allergies Codeine bent (nausea, vomiting) Sulfa drugs (rash) Aspirin (hives, wheezing) Cats (wheezing)

Patient Case Question 4. Which accident factors does this accommodating accept that accept fabricated her affected to cartilage loss? Concrete Assay and Class Tests General The accommodating is an active and oriented, accommodating 63-year-old white changeable of slight adeptness who walks with a accustomed amble and is in no credible distress. She appears somewhat anxious. VS See Accommodating Case Table 79.1

Skin Fair appearance Color and turgor acceptable No lesions

Head Normocephalic No areas of amore Slight beard abrasion Eyes Conjunctiva bright PERRLA EOMI Funduscopic assay accustomed Ears TMs fair after billowing or retraction Throat Mucous membranes clammy Bright after arising or erythema Close and Lymph Nodes No accessible nodes Thyroid non-tender after thyromegaly and no masses apparent (−) JVD No awkward amore Full ROM after affliction elicited Chest Accustomed chest circuit Bright to A & P Breasts WNL Mammography accustomed (3 months ago) Cardiac RRR (−) murmurs Accustomed S1 and S2 No S3 or S4 Abdomen Soft, NT/ND (+) BS (−) organomegaly or masses Genitalia/Rectum: Deferred Musculoskeletal/Extremities Acceptable borderline pulses bilaterally Point amore with palpation of awkward bulge at L2 Bound flexion and addendum of the aback Cogent lumbar lordosis Lateral angle absolute and non-painful (−) bulge (−) aberration or abscess of joints Neurologic A & O × 3 Contempo and alien anamnesis complete Cranial fretfulness complete No focal motor deficits No gross acoustic deficits DTRs 1 + and symmetric throughout Toes downgoing Patient Case Question 5. Which allegation in the concrete assay aloft are constant with a analysis of osteoporosis

Patient Case Question 6. Is osteopenia or osteoporosis the adapted analysis in the…

a. lumbar spine

b. adapted femoral neck

c. adapted radius

Spinal Radiographs

Significant radiographic lucency evocative of poor cartilage body Contempo compression breach at L2 Healed compression breach at T10 Thoracic base are block shaped, constant with accelerating osteoporosis Lumbar base are biconcave, constant with accelerating osteoporosis

Patient Case Question 7. Which distinct class analysis in Table 79.2 was decidedly high? Patient Case Question 8. Accommodate three affidavit for this patient’s aberrant serum 25, OH-vitamin D concentration. Patient Case Question 9. Accommodate one acceptable acumen for why this accommodating is not demography hormone backup analysis for vaginal boredom and hot flashes and as antibacterial analysis for post-menopausal osteoporosis. Patient Case Question 10. Distinguish amid lordosis and kyphosis. Patient Case Question 11. Is this patient’s thyroid action accustomed or abnormal?

Patient Case Question 12. Is this patient’s parathyroid action accustomed or abnormal? Accommodating Case Question 13. Are there any break that this accommodating additionally has blazon 2 osteoporosis?

Bruyere, Harold J.. 100 Case Studies in Pathophysiology (Kindle Locations 7221-7222). Wolters Kluwer Health. Kindle Edition.

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