Mrs. I.A. is a very pleasant 63-year-old white woman of slight stature who has been referred to an orthopedic specialist by her PCP. She has been experiencing insidious back pain for 5-6 weeks. OTC analgesics provide temporary relief, but the pain is otherwise constant and aggravated by activity. She denies any obvious acute injury to her back, although she reports that she had a case of the flu with a prolonged and severe cough approximately one month ago. She also reports a vertebral fracture approximately five years ago.

The patient has been an avid gardener for many years. Following the death of her husband 18 months ago, she has continued to live in her house and do all the household chores. Since her back pain began, she has been limited in her ability to do her household chores and gardening.

The patient entered natural menopause at 52 years and has never used hormone replacement therapy. Currently, she has mild hot flashes and vaginal dryness. At age 58, she suffered a vertebral fracture at T10 by simply carrying a shopping bag. DEXA scans conducted at that time revealed the onset of osteoporosis. Her bone mass density T-scores at that time were: - 3.33 lumbar spine, -2.24 right femoral neck, and -2.44 right radius. These scans represented a 6.1%, 6.9%, and 6.2% decrease in bone mass density in the previous 19 months in the lumbar spine, right femoral neck, and right radius, respectively. Her serum calcium concentration was low-normal at 8.5 mg/dL and serum alkaline phosphatase level was moderately increased at 290 IU/L. She was prescribed alendronate and a calcium supplement daily.

The patient was diagnosed with a seizure disorder at age 22 years and is currently well controlled with phenytoin. She has had asthma since childhood. Her current asthma medications include a bronchodilator that she uses when needed, a daily steroid inhaler, and an oral corticosteroid that she uses about four times per year for 3-6 weeks when symptoms worsen. She also takes a daily multivitamin tablet and has 1-2 dairy servings every day. She has noticed a slight reduction in height in recent years, but denies any significant changes in weight. She had an appendectomy at 11 years of age.

The patient has a positive family history of osteoporosis. Her older sister has experienced a hip fracture and her paternal aunt was diagnosed with an osteoporosis-related wrist fracture following a fall.

Her mother was diagnosed with breast cancer at age 56, but died from lung cancer at age 69. She also suffered from high blood pressure and "high blood sugar." Her father died at age 54 from AMI. Her brother (age 65) has HTN and high cholesterol, and her younger sister (age 57) has no known medical problems.

The patient smokes four cigarettes a day (down from 1½ ppd eight years ago) and drinks one glass of wine daily. Her main sources of dietary calcium are milk with her breakfast cereal and "some" cheese about three times a week. The patient is widowed and was married for 39 years until the death of her husband 1½ years ago. She has one son who is healthy. She had a miscarriage at age 19. She does most of her cooking and "watches what she eats." She denies non-compliance with her medications. She gets very little weight-bearing exercise. She uses SPF 30 sunscreen to protect herself from sunburn and skin cancer every time that she spends more than 15 minutes in the sun.

The patient denies any unusual bleeding, weakness, back spasms, shortness of breath, chest pain, fever, chills, heat or cold intolerance, and changes in her hair, skin, and nails. She reports vaginal dryness, occasional hot flashes and night sweats "maybe once every 6 months."

Medications

• Alendronate 10 mg po QD
• Calcium carbonate 1.25 g (500 mg calcium) po BID
• Multivitamin tablet po QD
• Phenytoin 100 mg po TID
• Albuterol MDI 2 puffs BID PRN
• Triamcinolone MDI 2 puffs QID
• Prednisolone 5 mg po BID PRN

• Codeine intolerance (nausea, vomiting)
• Sulfa drugs (rash)
• Aspirin (hives, wheezing)
• Cats (wheezing)

General

The patient is an alert and oriented, cooperative 63-year-old white female of slight stature who walks with a normal gait and is in no apparent distress. She appears somewhat anxious.

VS

See Patient Case Table 79.1

Skin

• Fair complexion
• Color and turgor good
• No lesions

• Normocephalic
• No areas of tenderness
• Slight hair thinning

Eyes

• Conjunctiva clear
• PERRLA
• EOMI
• Funduscopic exam unremarkable

Ears

TMs pearly without bulging or retraction

• Mucous membranes moist
• Clear without drainage or erythema

Neck and Lymph Nodes

• No obvious nodes
• Thyroid non-tender without thyromegaly and no masses palpable
• (-)JVD
• No bony tenderness
• Full ROM without pain elicited

Chest

• Normal chest excursion
• Clear to A & P

• WNL
• Mammography normal (3 months ago)

Cardiac

• RRR
• (-) murmurs
• Normal S₁ and s₂
• No S₃ or S₄

Abdomen

• Soft, NT/ND
• (+) BS
• (-) organomegaly or masses

Deferred

Musculoske!etal/Extremities

• Good peripheral pulses bilaterally
• Point tenderness with palpation of bony prominence at L2
• Limited flexion and extension of the back
• Significant lumbar lordosis
• Lateral bending unlimited and non-painful
• (-) kyphosis
• (-) deformity or swelling of joints

• A & O X 3
• Recent and remote memory intact
• Cranial nerves intact
• No focal motor deficits
• No gross sensory deficits
• DTRs 1+ and symmetric throughout
• Toes downgoing

See Patient Case Table 79.2

See Patient Case Table 79.3

• Significant radiographic lucency suggestive of poor bone density
• Recent compression fracture at L2
• Healed compression fracture at T10
• Thoracic vertebrae are wedge shaped, consistent with progressive osteoporosis
• Lumbar vertebrae are biconcave, consistent with progressive osteoporosis

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Abbreviations

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Abbreviations

Muscular-skeletal system physiology

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Muscular-skeletal system physiology