Osteoporosis

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents for a ‍newly diagnosed osteoporosisabnormal BMDfragility fracture

Fragility fractures: ‍none, ‍humeral head, ‍wrist, ‍dorsolumbar spine, ‍hip, ‍



Test results:

BMD: ‍normalosteopeniaosteoporosis, T-score ‍

FRAX score (10-year risk): hip fracture ‍‍%, major osteoporotic fracture ‍‍%



Associated symptoms: *Try using right-click for negatives*

‍bone pain

‍back pain

‍limited mobility

‍loss of height

‍kyphosis

‍difficulty walking



Contributing factors:

‍low calcium intake

‍sedentary lifestyle

‍smoking

‍alcohol abuse

‍excessive caffeine intake

‍low body weight

‍history of falls

‍menopause

no history of: ‍osteoporosis, ‍fractures

no use of: ‍corticosteroids, ‍calcium supplements, ‍vitamin D supplements, ‍bisphosphonates, ‍selective estrogen receptor modulators, ‍teriparatide, ‍denosumab, ‍raloxifene

no family history of: ‍osteoporosis





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Musculoskeletal: joints ‍ ‍normal, ‍limited ROM





ASSESSMENT:

‍Osteoporosis ‍likelysuspectedpossible

DDx: primary osteoporosis, rheumatoid arthritis, malabsorption syndromes, long-term corticosteroid use, anticonvulsant use, aromatase inhibitor use, hyperparathyroidism, hyperthyroidism, osteomalacia, multiple myeloma, bone metastases, chronic renal failure, vitamin D deficiency, calcium deficiency, eating disorders, ovarian insufficiency, chronic liver disease, alcoholism, smoking, low body weight, sedentary lifestyle, Cushing's syndrome, prolonged immobilization, androgen deprivation therapy, inflammatory bowel disease





PLAN:

Investigations:

- FRAX score calculation

- Blood work: ‍CBC, ‍creatinine, ‍electrolytes, ‍TSH, ‍calcium, ‍phosphate, ‍albumin, ‍vitamin D, ‍PTH, ‍alkaline phosphatase, ‍serum protein electrophoresis, ‍testosterone, ‍FSH, ‍LH, ‍prolactin, ‍anti-transglutaminase

- Urine: ‍24-hour urine calcium

- Bone mineral density test

- X-ray of spine

Treatments:

- ‍Vitamin D supplements

- ‍Calcium supplements

- ‍Bisphosphonates

- ‍Denosumab (

- ‍Teriparatide

- ‍Raloxifene

- ‍Hormone replacement therapy

- Increase dietary intake of vitamin D-rich and calcium-rich foods (milk, yogurt, cheese, sardines, salmon, tofu, almonds, spinach, kale, broccoli)

- Weight-bearing exercises

- Limit alcohol intake

- Avoidance of smoking

- Fall prevention measures

- Consider stopping biphosphonates after 5 years of treatment if BMD is stable and no new fractures

Further care:

- Repeat bone mineral density test in ‍1235 ‍years

- Referral to endocrinologist

- Follow-up in ‍ ‍monthsyears

- Return if new symptoms develop such as back pain, height loss, or fractures