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osteoporosis (alhanoof and maram)

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alhanoof esam

on 26 June 2013

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Transcript of osteoporosis (alhanoof and maram)

osteoporosis
Done by :
Alhanoof
Maram
Case scenario
MA is a 60 years old postmenopausal Caucasian female with a history of hypertension, hyperlipidemia, COPD, and hypothyroidism. She lives alone in her department from 5 years after her husband has died, heavy smoker (2 packets/day) from 7 years and Alcoholic 2 cups/day.

She brought to the emergency department in the morning (4:00 am) by her neighborhood suffering from severe back pain and stiffness , she said: I slipped on the kitchen floor yesterday at (11:15 pm) when I drank a cup of water, then I got back to my bed because of pain, but the pain did not stop and increased, which made me unable to move , also she told her doctor that she hears sounds from her cartilage.
chief compliant
She brought to the emergency department in the morning (4:00 am) by her neighborhood suffering from severe back pain and stiffness
MA is a 60 years old postmenopausal Caucasian female with a history of hypertension, hyperlipidemia, COPD, and hypothyroidism brought to the emergency department in the morning (4:00 am) by her neighborhood suffered from severe back pain and stiffness , unable to move , also she told her doctor that she hear sounds from her cartilage.
History of Present Illness
Past Medical History
Hypertension first diagnosis at age 56
Menopause at age 50
Hyperlipidemia X 8 years , patient modified diet and took cholestyramine for several years.
COPD X 4 years ago, history of repeated exacerbation requiring prednisone, last exacerbation 4 months ago. Currently stable on multiple inhalers.
Hypothyroidism X 17 years ago, treated with levothyroxine.
Poor vision (uncontrolled).
Current medication
Ramipril 10 mg PO BID X 2 years

Albuterol MDI 2 puffs Q 6 hrs PRN

Tiotropium 18 mcg inhaled once daily X 9 months.

Advair 250/50 1 puff BID X 9 months

levothyroxine 100 mcg PO once daily

Atenolol 50 mg PO once

Lipitor 10 mg PO once daily

Acetaminophen (without prescription)
Family History
Paternal history (+) for CAD; father died at age 60 of “heart disease”
mother became menopausal at approximately age 40 and died with history of osteoporotic fracture of the hip and spine.
Her older sister with osteoporosis.
Social History
She lives alone in her department for 5 years after her husband was died.

smoker 2 packets/day for the last 15 years.

Alcoholic 2 cup/day.
Review Of System
Severe pain the pain did not stop and increase, that made her unable to move , also she told her doctor that she hears sounds from her cartilage.
Headache

Physical Examination Diagnostic Evaluation
Signs and symptoms

Lab results

DXA scan

X-ray
Physical examination
All
NKDA
Allergies:
NKDA
Chest:
Decreased breath sounds bilaterally
air movement decreased
no rales or rhonchi
HEENT:
poor vision , and hear
Skin:
Fair complexion, color good, no lesion
Vital Signs:
BP 130/84 mmHg
P 64
RR 17
T 37˚C
Weight (53.5 kg)
Height 170 cm
General:
WDWN Caucasian woman
Laboratory test
Na 141 mEq/L (135 – 145 )
K 4.2 mEq/L ( 3.5 - 5.0 )
Cl 104 mEq/L ( 98-108 )
Ca 4 mEq/dl (8.4 - 10.2)
Ph 2.6 mg/dl (3.0 - 4.5)
Scr 1.0 mg/dl (0.9-1.3)
Glu 98 mg/dl (65-99 )
LDL 167 mg/dL (Less than 100)
HDL 30 mg/dL (60 and above)
TG 265 mg/dL (Less than 150)
T.chol 250 mg/dL (Less than 200)
DXA scan
Right formal neck = 0.615 g/cm² (T-score: -3.1 SD)

X-ray of the spine show compression fracture on L3
Others:
Problem List:
Calculation:
BMI (kg/m²) =

53.5 kg
-------------------------——= 18.44
2.90 m²
creatinine clearance calculation :
(140 – 60 ) X 53.5
------------------------------------------------------------ X 0.85 = 50.5 ml/min
72 X 1.0
hypertension
hyperlipidemia,
COPD (Chronic obstructive pulmonary disease)
hypothyroidism
poor vision
smoker and Alcoholic
postmenopausal
Normal Range :
(88-128) ml/min
SOAP
note

subjective
Severe Back Pain

Stiffness

She hears a sound from her joints when she stand up
Objective
Weight (53.5 kg)
Height 170 cm
crcl : 50.5 ml/min
BMI (kg/m²) = 18.44
DXA scan Right formal neck = 0.615 g/cm² (T-score: -3.1 SD)X-ray of the spine show compression fracture on L3
objective
objective
objective
objective
vital sign:
Lab result:
Na 141 mEq/L (135 – 145 )
K 4.2 mEq/L ( 3.5 - 5.0 )
Cl 104 mEq/L ( 98-108 )
Ca
4 mEq/dl (8.4 - 10.2)
Ph
2.6 mg/dl (3.0 - 4.5)
Scr 1.0 mg/dl (0.9-1.3)
Glu 98 mg/dl (65-99 )
LDL
167 mg/dL (Less than 100)
HDL
30 mg/dL (60 and above)
TG
265 mg/dL (Less than 150)
T.chol
250 mg/dL (Less than 200)
DXA scan and X-ray
Assessment
Assessment
Assessment
Assessment
60 years old postmenopausal Caucasian female with hyperlipidemia, hypertension. She present to the emergency suffered from sever back pain.
According to the physical examination, diagnostic evaluation, risk factor:

patient's diagnosis is postmenopausal osteoporosis
Risk Factor
Age (>50 years).
sex (female).
Ethnicity: (Caucasian), Although adults from all ethnic groups are susceptible to developing osteoporosis, Caucasian and Asian women and men face a comparatively greater risk.
Family history of osteoporosis, particularly maternal history of fractures .
Smoking: smokers are at higher risk.
Alcohol consumption.
Calcium and vitamin D intake.
Low body weight, low BMD.
Signs of vertebral fracture.
Hormonal Deficiencies:( Menopause), Events associated with estrogen deficiencies are the primary risk factors for osteoporosis in women. These include:
Menopause. Within 5 years after menopause, the risk for fracture increases dramatically. Fractures occurring during this period are more likely to occur in the wrist or spine than the hip, but their occurrence is a strong predictor of later severe osteoporosis and hip fracture.
Risk factors for falls in older patients: these include poor balance, , weakness of the lower extremity muscles and deconditioning, use of medications with sedative effects, poor vision or hearing, and cognitive impairment.
Osteoporosis
Osteoporosis: Thinning of the bones, with reduction in bone mass, due to depletion of calcium and bone protein. osteoprosis predisposes a person to fractures, which are often slow to heal and heal poorly.
Plan
(the primary goal is prevention)
Reduce future falls and fractures .
Improve functional capacity.
Reduce pain and deformity.
Stabilized or improve bone mass and strength.
Prevent fracture.
Minimize symptoms of osteoporosis.
Minimize adverse effects of medications
improve quality of life
Other physical examinations yield a normal result.
Plan
Osteoporosis prevention and treatment begins with a bone-healthy lifestyle and uses nonprescription and prescription medications as needed.
Plan
Plan
Diet
exercise
Fall Prevention
2
4
5
Hip Protector
smoking cessation
2
4
5
NonPharmacological Therapy
Hip protectors are shock-absorbing pads that can be worn to cushion the impact over the hip bone, when a person fall down.
Pharmacological Therapy
Patient Counseling
Enhancing medication adherence
Actively engage the patient in care
Education, so patients become more informed about their illness
Education about effectiveness and side effect of treatment
Teach patients and families self-monitoring techniques
Patients should be instructed that the expected benefits of alendronate may only be obtained when each tablet is swallowed with plain water immediately upon arising for the day and at least 30 minutes before the first food, beverage, or medication of the day. 
Even dosing with orange juice or coffee has been shown to markedly reduce the absorption of alendronate.
To facilitate delivery to the stomach, and thus reduce the potential for esophageal irritation, patients should swallow alendronate with a full glass of water (6–8 ounces) 30 minutes before the first food of the day and avoid lying down for at least 30 minutes after taking the tablet.Patients should be advised that the risk of severe esophageal adverse experiences increases if the complete dosing instructions are not followed.
Patients should not chew or suck on the tablet because of a potential for oropharyngeal ulceration. 
In addition, patients should be specifically instructed not to take alendronate at bedtime or before arising for the day. If they develop symptoms of esophageal disease (such as difficulty or pain swallowing, retrosternal pain, or new or worsening heartburn), patients should be instructed to stop taking alendronate and consult their physician
Do not administer drugs 2 hrs before and 1hr after
Most patients prefer once-weekly or once-monthly administration
If miss a weekly dose, can take it the next day, if more than 1 day, dose is skipped until next scheduled.
If miss monthly dose, can take it up to 7 days before next administration
Monitoring and follow up
the efficacy , side effects , signs and symptoms
SCr at baseline; bone mineral density at baseline if glucocorticoid tx, then at 6-12 months .
Ca, s/s of hypocalcemia if mineral metabolism disorder hx central DXA measurement
Therapeutic outcome
Assessment of response done subjectively

How clinician feels patient is doing

Height , weight

T-score , Z-score , DXA measure
Evidence
pubmed.com
pharmacotherapy principle and practice
Full transcript