Posted: November 7th, 2016

What information (signs, symptoms, laboratory values, and FRAX score) indicates the presence or severity of the patient’s osteoporosis? What are the patient’s risk factors for osteoporosis?

Patient Presentation

Chief Complaint

“I am anxious to get the results of my DXA scan. My mother is still undergoing rehabilitation in the nursing home, after her hip fracture three weeks ago. I’ve heard osteoporosis can run in families, and I don’t want to experience what she is going through.”

HPI

Elliana Mitchell is a 65-year-old woman with a history of COPD, hypothyroidism, and GERD. She presents to the family medicine clinic for her yearly physical and to discuss the results of her recent labs and DXA scan.

In an effort to become more active, she recently started walking around her neighborhood every day, but has to stop after 15 minutes because she is out of breath. She admits that she has a hard time remembering to take her medications faithfully. She states she uses her Combivent inhaler approximately twice a day and takes her medicines “most of the time.”

PMH

Hypothyroidism × 5 years

COPD (GOLD 2) diagnosed 1 year ago and currently stable; no history of COPD exacerbations

Breast cancer with mastectomy of left breast and radiation therapy at age 45

Menopause at age 51

GERD

 

FH

Paternal history (+) for hypertension; father died in his sleep at age 80

Maternal history (+) for stroke and vascular disorders; hip fracture

 

SH

Married; G₂P₃; 1 ppd smoker; drinks occasionally

 

ROS

Reports vaginal dryness; has noticed that her height has decreased by 2″ since she was “in her prime;” reports shortness of breath with exercise; denies headache, chest pain, GI pain, or heartburn

 

Meds

Combivent Respimat 1 inhalation four times daily

Omeprazole 20 mg po once daily × 1 year

Synthroid 75 mcg po once daily × 5 years

 

All

NKDA

 

Physical Examination

Gen

WDWN Caucasian woman in NAD

VS

Today:

BP initially: 158/96 mm Hg, Repeated at end of office visit: 148/92 mm Hg

P 70 bpm, RR 18, T 37°C; Wt 53.5 kg, Ht 5′3″

 

1 month ago:

BP 146/94 mm Hg, P 66 bpm, RR 20, T 37°C; Wt 53.5 kg, Ht 5′3″

 

Skin

Fair complexion, color good, no lesions

 

HEENT

PERRLA; EOMI; eyes and throat clear; funduscopic exam reveals mild arteriolar narrowing, with AV ratio 1:3; no hemorrhages, exudates, or papilledema

Neck/Lymph Nodes – Supple, without obvious nodes; no JVD

 

Chest – Decreased breath sounds bilaterally; air movement decreased; no rales or rhonchi

Breasts – Mastectomy scar left breast; right breast normal

CV – RRR; no murmurs, rubs or gallops

Abd – Soft, NT/ND, (+) BS

Genit/Rect – Deferred

MS/Ext -Good pulses bilaterally

Neuro – CN II–XII intact; DTRs 2+; sensory and motor levels intact

Labs

 

Na 145 mEq/L	Ca 9.1 mg/dL
K 4.0 mEq/L	TSH 3.492 mIU/L
Cl 104 mEq/L	AST 32 IU/L
CO2 25 mEq/L	ALT 27 IU/L
BUN 18 mg/dL
SCr 1.1 mg/dL
Glu 97 mg/dL

 

Other

DXA scan results from Hologic machine:

Lumbar spine 2 weeks ago reveals: L2–4 = 0.780 g/cm² (T score: −3.2 SD); right femoral neck = 0.52 g/cm² (T score: −2.8 SD).

X-ray of the spine 2 weeks ago shows a compression fracture on L3.

mMRC grade 2.

 

Assessment

1. Severe osteoporosis requiring initiation of therapy
2. Hypertension newly diagnosed today
3. Stable COPD Patient Group B (GOLD 2)
4. Hypothyroidism well controlled on current regimen

 

Clinical Pearl

In elderly patients or those on acid-suppressive therapy, recommend calcium citrate instead of calcium carbonate, as this salt form does not require an acidic gastric pH for dissolution.

Questions

Problem Identification

1.a. Create a list of the patient’s drug therapy problems.

1.b. What information (signs, symptoms, laboratory values, and FRAX score) indicates the presence or severity of the patient’s osteoporosis? What are the patient’s risk factors for osteoporosis?

 

Desired Outcome

2. What are the goals of pharmacotherapy for osteoporosis in this case?

Therapeutic Alternatives

3.a. What nondrug therapies might be useful for this patient’s osteoporosis?

3.b. What feasible pharmacotherapeutic alternatives are available for treatment of the osteoporosis?

 

Optimal Plan

4.a. What drug, dosage form, dose, schedule, and duration of therapy are best for treating this patient’s osteoporosis?

4.b. What alternatives would be appropriate if the initial therapy fails or cannot be used?

 

Outcome Evaluation

5. Which clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects?

Patient Education

6. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?