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CQC Nazish Ekram 10

Endocrine Clinic: New Patient Visit. ID: 50 year old woman CC: DEXAHPI: Otherwise healthy 50 yo woman who had DEXA scan done for screening post-menopause; found to have significant osteoporosis. Initial workup also showing Vitamin D deficiency.PMH:GERDAllergic RhinitisMedsAllegra 1 tab daily

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CQC Nazish Ekram 10

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    1. CQC Nazish Ekram 10/21/08

    2. Endocrine Clinic: New Patient Visit ID: 50 year old woman CC: +DEXA HPI: Otherwise healthy 50 yo woman who had DEXA scan done for screening post-menopause; found to have significant osteoporosis. Initial workup also showing Vitamin D deficiency. PMH: GERD Allergic Rhinitis Meds Allegra 1 tab daily Vitamin D 50,000 units weekly

    3. All: Penicllin ? rash Erythromycin ? nausea SH: Divorced, lives with youngest of 2 daughters. Will start working in a couple weeks. Quit smoking over 20 years ago; previously smoked 1 ppd for two years. H/o heavy alcohol use in 20s-40s, now none FH: Mother and sister (49 yo) with osteoporosis, no fracture history ROS: Gen: No weight change, fevers, chills, night sweats HEENT: No changes/problems with vision, hearing. No difficulty swallowing. Neck: No neck stiffness. Lungs: No shortness of breath, cough. Heart: No chest pain, palpitations. GI: + GERD. No black/bloody stools. No BRBPR. GU: No dysuria, urinary frequency, hematuria MS: No arthritis Ext: No pain, weakness, numbness Heme: No history of easy bruising or clotting. No history of cancer.

    4. Physical Examination Vitals: BP 106/62 Pulse 62 Height 166 cm Wt 65 kg General Appearance: alert, well developed, in no acute distress Eyes: No lid lag, no perioribal edema and no stare HEENT: small around 1 cm, left, no cervical lymphadenopathy + Chvostek’s sign Neck: Possible thyroid nodule Back: no kyphosis or back tenderness Respiratory: clear to auscultation bilaterally Cardiovascular: RRR, nl S1 S2 Gastrointestinal: soft, nontender, normal bowel sounds Neuro: Motor and sensory grossly intact. Bilateral hyperactive reflexes Musculoskeletal: normal muscle strength and tone

    5. DEXA Scan Results

    6. Question: How can we work up secondary causes of osteoporosis? When should we work it up?

    7. Diagnosis Osteoporosis is characterized by low bone mass, leading to increased chance of fracture. Diagnosed by the measurement of bone mineral density by way of the DEXA scan (dual energy x-ray absorptiometry) T-Score: standard deviation (SD) difference between a patient's BMD and that of a young-adult reference population Z-Score: SD difference between a patient’s BMD to an age-matched population.

    8. How do we use these numbers?

    9. Assessing Risk Factors History of fractures, loss of height Postmenopausal Maternal history History of kidney stones Low calcium intake Malabsorption (ex: celiac sprue) Falls Glucocorticoid, antiseizure therapy Smoking Alcohol

    10. Secondary Causes of Osteoporosis Endocrine Hyperparathyroidism Hypogonadism Calcium deficiency Cushing’s syndrome and disease Hypercalciuria Hyperthyroidism GH Deficiency Inflammatory conditions (RA, AS, IBD) Medications (glucocorticoids, cyclosporine, antiseizure, heparin, chemotherapy, GnRH agonists) GI Malabsorption (IBS, IBD, celiac sprue, gastrectomy, TPN) Alcohol-related liver disease Renal disease Cancer (MM, lymphoproliferative diseases) BM-related disorders Congenital (Osteogenesis imperfecta, homocystinuria)

    11. Initial Workup for Secondary Causes Chemistry Alkaline phosphatase CBC Calcium (Ionized) Phosphorous 25-(OH)D TSH PTH Celiac markers

    12. Initial Workup for Secondary Causes Chemistry 142 103 10 3.7 30 0.77 Alkaline phosphatase 60 (30-110) CBC WNL Calcium (Ionized) 7.31 (7.32-7.42) Phosphorous 4.2 (2.6-4.4) 25-(OH)D 22 (30-80) TSH 0.9 (0.4-4.4) PTH 39 (10-65)

    13. Additional Workup 24 hour urine calcium Estradiol, LH, FSH, prolactin 1,25 (OH) Vitamin D Celiac screen SPEP/UPEP ESR RF Fe, TIBC Homocysteine Urine cortisol LFTs

    14. When do we workup secondary osteoporosis?

    15. Take Home Points Diagnosis of osteoporosis made by DEXA Scan T Score < -2.5 After initial diagnosis, BMD (not T or Z score) used to track disease progression An initial workup for secondary causes should always be done, especially for Z scores < -2

    16. References Osteoporosis prevention, diagnosis, and therapy. JAMA 2001; 285:785 Raisz LG “Screening for Osteoporosis”. N Engl J Med 353:164, July 14, 2005 Clinical Practice. Kanis, JA, Melton, LJ, 3rd, Christiansen, C, et al. The diagnosis of osteoporosis. J Bone Miner Res 1994; 9:1137. Diagnosis of osteoporosis in men, premenopausal women, and children. J Clin Densitom 2004; 7:17. Lewiecki, EM. Premenopausal bone health assessment. Curr Rheumatol Rep 2005; 7:46. UpToDate Rubin, MR, Schussheim, DH, Kulak, CA, et al. Idiopathic osteoporosis in premenopausal women. Osteoporos Int 2005; 16:526.

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