Vol. 5 •Issue 23 • Page 32
Osteoporosis: Case Study
Case presentation and history give clues to diagnosis of osteoporosis
T.S. is a 52-year-old white female experiencing diffuse bone pain over the past several years after menopause. She has a history of fractures to her left hip and wrist. She states, “The pain is becoming worse and it is keeping me from doing my daily activities.” She currently complains that any weight-bearing activity causes her severe discomfort.
She is not taking hormone replacement or any other medication. She has been using a soy herbal supplement and vitamin E 400 IU daily. She knows the importance of preventive healthcare.
She is up to date on all her gynecological exams, and past mammograms have been normal as have her health maintenance exams. She does not smoke or use alcohol. Her system reviews are unremarkable excluding today’s complaint.
Her family history reveals that her mother had a history of anxiety, osteoporosis, non-insulin dependent diabetes and hypertension. Her father has hypertension but is in otherwise good health. There is no history of breast disorders or arthritis, thyroid or any other metabolic disorder.
She lives alone in a one-story house and works at a car plant. She has three children and one grandchild. Her daughter lives in close proximity to her so she is able to enjoy visiting and caring for her 3-year-old grandson occasionally. She has no exercise routine and admits to a somewhat sedentary lifestyle. She admits to eating a vitamin-poor diet.
T.S. experienced menopause around the age of 47 when her menstrual periods stopped. Her previous physician recommended no hormone replacement because she was not suffering from any menopausal symptoms. However, she now reports having “hot spells” at different times throughout the day with some trouble sleeping for the past 3 months. She also complains of some vaginal dryness that she admits is bothersome.
Her chief complaint is severe back pain and the inability to do simple chores such as lifting grocery bags and her grandchild without pain.
Upon physical exam, she is afebrile with unremarkable findings with exception to the musculoskeletal system. She weighs 132 pounds and is 5 feet 5 inches. At her last exam 8 months ago, she was 5 feet 6 inches.
Upon palpation, guarding and tenderness are present in the cervical, thoracic and lumbar spine with limited range of motion. No spasticity, rigidity or flaccidity is present. She has active range of motion in all joints, with no edema, redness or heat present in joint areas. She exhibits notable guarding and rigidity performing range of motion of lower and upper back areas.
There is also noticeable guarding with some limitation of movement at the cervical spine area. She is able to endure the exam with noticeable painful expressions on her face when asked to do range of motion with back, guarding and tenderness noted at cervical spine area. There is no presence of dowager’s hump. She has no evidence of herniation or disc displacement upon inspection. No scoliosis or lordosis is present.
Her preliminary urinalysis and CBC are unremarkable.
Her symptoms indicate post-menopausal osteoporosis. In addition to physical findings, T.S. has risk factors of increased age, heredity, small body size, thin stature and being white.1
To confirm the diagnosis and rule out other medical conditions, lab tests were obtained to assess hormone, calcium, vitamin D, blood cholesterol levels and thyroid function. Also ordered were a sedimentation rate to check for arthritis, an X-ray of her back and a dual energy X-ray absorptiometry (DEXA) scan to rule out injury. DEXA scan is the gold standard in diagnosis of osteoporosis.2
Diagnostic tests revealed a lack of estrogen and calcium. The X-ray of her back showed degenerative changes but no disc dislocations or herniations. The DEXA scan showed a T score of -2.9. A T score greater than -2.5 confirms a diagnosis of osteoporosis and indicates hormonal treatment should be initiated.1
Treatment includes a calcium supplement 1200 mg with vitamin D daily, Fosamax® (alendronate sodium) 10 mg daily and Premarin® (conjugated estrogens) 0.625 mg daily. This routine treatment should provide adequate relief and help prevent future bone loss.3 The Women’s Health Initiative study is the first trial with definitive data supporting the ability of postmenopausal hormones to prevent fractures at the hip, vertebrae and other sites.4
After tolerance of medications and symptom relief have been achieved, a walking routine, weight-bearing exercise and education on a well-balanced diet are introduced. The goal of walking and weight-bearing exercises is to increase bone mass and muscle endurance.
In addition to the nutritional education, T.S. is given reinforcement on continuing to avoid alcohol and cigarette smoking. Education also includes the side effects of taking estrogen and Fosamax and the importance of following this treatment plan to achieve a good outcome for her, as osteoporosis is a debilitating condition.
With this patient’s heredity, risk factors and menopausal state, her risk for osteoporosis is high. With the hormonal changes of menopause alone, there has been a great decrease in calcium absorption levels. Hormone replacement needs to be used to increase the absorption of the calcium, vitamin D and estrogen concurrently to prevent further bone loss and increase her quality of life.
Though there are now many studies that show negative impacts of the use of estrogens on menopausal women, in this patient the use of Fosamax and Premarin should help her greatly and increase her quality of life.1 With proper treatment and follow-up, she should be able to live a normal life with less bothering symptoms in the future.
1. McKalip, D. (2003). Case study: A 78-year-old female with a 4-week-old fracture from primary osteoporosis. The Journal of Family Practice, 52(2), 115-117.
2. South, J.E. (2001). Osteoporosis: Part 1, evaluation and assessment. American Family Physician, 63, 897-904.
3. McClung, B. (1999). Using osteoporosis management to reduce fractures in elderly women. The Nurse Practitioner, 24(3), 26-49.
4. Writing Group for the Women’s Health Initiative Investigators. (2002). Risks and benefits of estrogen plus progesterone in healthy postmenopausal women: Principle results from the women’s health initiative randomized controlled trial. JAMA, 288(3), 321-333.
Natalie Tesso Simmermacher is a nationally certified wound, ostomy and continence advanced practice nurse. She is completing the final stages of a family nurse practitioner program. She is a published author, professional speaker and has her own practice in Ohio.