St Thomas University Week 5 E

  • Elizabeth Varona-Martin

Module 5

My clinical experience this week has been very hectic. As the winter months approach, the medical office becomes busier than usual with the arrival of the snowbirds.

Snowbird is a term used to name retired people from northern states that come south to escape the harsh winters. They have a massive impact on Florida’s local health care provider’s attempt to provide services for an influx of temporary customers on top of an already overburdened plate of local patients. Learning about time management has been a valuable lesson for our experience as healthcare providers. The ability to prioritize our day is critical to our overall performance. 

G.L., a 65-year-old Hispanic female came to the office for evaluation of osteoporosis. Approximately two years ago, she developed swelling and sharp back pain after preventing her sewing machine from falling to the floor. She was treated for roughly a year symptomatically before physical therapy. MRI documented compression fractures at T8-T9 level and T12. In August 2016, she received an infusion of Reclast. Weeks later, she started noticing the attenuation of pain. She has not had a fall and denies balance issues. She is supplementing calcium and vitamin D. She has a very healthy lifestyle. She has not been exercising because of what was mentioned above. The patient denies caffeine, alcohol, or nicotine consumption. 

She is currently treated with Prolia 80mg Subcutaneous every six months.

DEXA scan in July 2020 showed a T score of -3.7 at L1-L4 level and -2.8 left femoral neck.

Vital signs:

Ht: 5’1  WT: 126 lb  BMI: 23.73    B/P: 130/80  HR: 68bpm  RR: 16 RPM  O2Sat: 98%

Differential diagnosis

Osteomalacia: is a condition characterized by poor mineralization of freshly produced osteoid at bone turnover sites. Mineralization problems happen due to insufficient calcium, phosphate, alkaline phosphatase levels, defective bone matrix, or direct mineralization inhibition (Cohen & Drake, 2021).

Multiple myeloma: The neoplastic development of immunoglobulin-producing plasma cells distinguishes multiple myeloma (MM). Most patients present with signs or symptoms of anemia, bone discomfort, increased creatinine or serum protein, tiredness, and hypercalcemia (Laubach, 2021).

Paget disease: (PDB) is a focal disorder of the bone metabolism in the aging skeleton, also known as osteitis deformans; it is characterized by accelerated bone remodeling that leads to bone overcrowding at single or multiple sites (monostotic PDB) with a deteriorated integration. Bone overcrowding is the main reason for PDB disease. Skull, spine, pelvic and lengthy lower extremities bones are commonly afflicted (Charles, 2020).

Osteoporosis: is characterized by low bone mass, microarchitectural disruption, and skeletal fragility, leading to lower bone strength and higher fracture risk (Rosen & Drezner, 2021). Until a fracture occurs, osteoporosis has no clinical signs. Fracture complications include pain, deformity, incapacity, and loss of height.

In addition to bone mineral density (BMD), decreased bone strength is related to many other factors, such as bone formation and resorption turnover, bone geometry (bone size and shape), and microarchitecture (Rosen & Drezner, 2021).

Impression and Plan

Diagnosis

ICD10-CM  M81.0 Osteoporosis

Labs : CMP and  25-hydroxyvitamin D levels in 6 months

Bone Density Scan due in July/2022

Prolia 60mg Subcutaneous given in the office today,

Follow up in 6 months to review lab results and Prolia injection.

Clinicians should perform a history, physical examination, and basic laboratory assessment on all postmenopausal women with osteoporosis. The initial laboratory studies should include a complete blood count (CBC), CMP, and 25-hydroxyvitamin D levels.

Without measuring BMD, a clinical diagnosis of osteoporosis can be made in the presence of a fragility fracture, notably at the spine, hip, wrist, humerus, rib, and pelvis. According to the World Health Organization (WHO) classification, in the absence of a fragility fracture, BMD evaluation by dual-energy x-ray absorptiometry (DXA) is the standard test for diagnosing osteoporosis. A DXA T-score ?-2.5 is consistent with osteoporosis, while a T-score between -1 and -2.5 indicates a low bone mass or osteopenia (Rosen & Drezner, 2021).

References

Charles, J. F. (2020, October 12). UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-paget-disease-of-bone?search=Paget+disease%3A&source=search_result&selectedTitle=1~118&usage_type=default&display_rank=1. 

Cohen, A., & Drake, M. T. (2021, July 16). Epidemiology and etiology of osteomalacia. UpToDate. Retrieved from https://www.uptodate.com/contents/epidemiology-and-etiology-of-osteomalacia?search=OsteomalaciaSource=search_result&selectedTitle=2~143&usage_type=default&display_rank=2. 

Laubach, J. P. (2021, May 14). Multiple myeloma: Clinical features, laboratory manifestations, and diagnosis. UpToDate. Retrieved from https://www.uptodate.com/contents/multiple-myeloma-clinical-features-laboratory-manifestations-and-diagnosis?search=Multiple+myeloma&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. 

Rosen, H. N., & Drezner, M. K. (2021, March 10). Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women. UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-evaluation-of-osteoporosis-in-postmenopausal-women?search=osteoporosis&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=2#H3329078. 

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