Osteoporosis

Chief Complaint
“I recently fell while walking, and my lower back is sore. I would also like 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
Sarah is a 60-year-old Caucasian woman with a history of hypertension, 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 fell 3 days ago and injured her back. She admits that she has a hard time remembering to take her
medications faithfully. She states she takes her medicines “most of the time.” She states that she was
prescribed alendronate 2 years ago but that she is “afraid of its side effects” and did not start it.

PMH
Hypothyroidism × 5 years
Hypertension
Breast cancer with mastectomy of left breast and radiation therapy at age 45
Menopause at age 51
GERD with history of esophageal stricture

FH
Paternal history (+) for hypertension; father died in his sleep at age 80
Maternal history (+) for stroke and vascular disorders; hip fracture

SH
Married; G2P2; drinks occasionally, retired real estate agent, lives independently with her husband and
dog, manages her own medicines, completed college, does not have a Medicare Part D plan

Meds
Omeprazole 20 mg PO once daily × 1 year
Levothyroxine sodium (Synthroid) 75 mcg PO once daily × 5 years
Hydrochlorothiazide 25 mg PO once daily
All
NKDA

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

PE
Gen
WDWN Caucasian woman in NAD, ambulating with a cane
VS
Today
BP initially 133/88 mm Hg sitting, repeated at end of office visit 100/64 mm Hg standing, P 70 bpm sitting
90 standing, RR 18, T 37°C; Wt 53.5 kg, Ht 5′3″
Timed Up and Go (TUG) test: 15 seconds
1 month ago
BP 130/82 mm Hg, P 66 bpm, RR 20, T 37°C; Wt 53.5 kg, Ht 5′3″
Skin
Fair complexion, no lesions
HEENT
PERRLA; EOMI; eyes and throat clear; normal dentition
Neck/Lymph Nodes
Supple, without obvious nodes; no JVD, no thyromegaly
Chest
Clear to auscultation; no rales or rhonchi
Breasts
Mastectomy scar left breast; right breast normal
CV
RRR; no MRG
Abd
Soft, NT/ND, (+) BS, no mass, no hepatosplenomegaly
Genit/Rect
Deferred
MS/Ext
Good pulses bilaterally, spine straight without scoliosis, moderate kyphosis, tender midthoracic
tenderness to palpation, no stigmata of Cushing disease
Neuro
CN II–XII intact; DTRs 2+; sensory and motor levels intact
Labs

Other
DXA scan results from Hologic machine 2 weeks prior:
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 today shows a compression fracture in T10
Patient is referred to fracture liaison service for coordination of care

Assessment
1. Osteoporosis
2. Hypertension with orthostasis
3. Hypothyroidism
4. GERD with esophageal stricture history
5. History of breast cancer 10 years ago
Questions:
Collect Information
1.a. What subjective and objective information indicates the presence of osteoporosis?

Assess the Information

2.a. Assess the severity of osteoporosis based on the subjective and objective information available.

2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of
medication appropriateness, effectiveness, safety, and patient adherence.

Develop a Care Plan
3.a. What are the goals of pharmacotherapy in this case?

3.b. What nondrug therapies might be useful for this patient?

3.c. Create an individualized, patient-centered, team-based care plan to optimize medication therapy for
this patient’s osteoporosis and other drug therapy problems. Include specific drugs, dosage forms, doses,
schedules, and durations of therapy.





















3.e. What alternatives would be appropriate if the initial care plan fails or cannot be used?

Implement the Care Plan

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

Follow-up: Monitor and Evaluate

5.a. What clinical and laboratory parameters should be used to evaluate the therapy for achievement of
the desired therapeutic outcome and to detect or prevent adverse effects?

Efficacy:

Toxicity/adverse effect:


5.b. Develop a plan for follow-up that includes appropriate time frames to assess progress toward
achievement of the goals of therapy.

Bonus Assignment Question:

1. Create a list of medications and disease states that associated with an increased risk for developing
osteoporosis.