Posted: November 7th, 2016
“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.”
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.”
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
Paternal history (+) for hypertension; father died in his sleep at age 80
Maternal history (+) for stroke and vascular disorders; hip fracture
Married; G2P3; 1 ppd smoker; drinks occasionally
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
Combivent Respimat 1 inhalation four times daily
Omeprazole 20 mg po once daily × 1 year
Synthroid 75 mcg po once daily × 5 years
WDWN Caucasian woman in NAD
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″
Fair complexion, color good, no lesions
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
|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|
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.
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.
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?
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?
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?
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