Explain the biological (genetic and neuroscientific); psychological (behavioral and cognitive processes, emotional, developmental); and social, cultural, and interpersonal factors that influence the development of psychopathology.
Case 5 : Osteoporosis #6270325 Victor John Barcarse BSN,RN,CCRN Charles Drew University of Medicine and Science NUR 630 Primary Care of Adult and Aged Dr. Obiageli Chidi, DNP, FNP-C, MSN, MBA March 18, 2020
Case 5 : Osteoporosis #6270325
CHIEF COMPLAINT: Patient is here for Routine Check-up and medication refill
HISTORY OF PRESENT ILLNESS: Patient is here for Medication Refill and she has no other complaints. Previous Dexa scan shows (+) osteoporosis. She is taking Calcium with vitamin D, Vitamin D 50,000IU Q weekly and Alendronate Q weekly. She does not have history of falls. Does not use any assistive devices. She does not complain of back pain at this time but when she does have back pain, she uses Ibuprofen 800MG PO BID PRN.
ALLERGIES: No Known Allergy
PAST MEDICAL HISTORY: Hyperlipidemia, Osteoporosis, Spinal Stenosis. Flu Vaccine last visit
SURGICAL HISTORY: None
FAMILY HISTORY: No family history
SOCIAL HISTORY: Widowed and retired. non-smoker. Does not drink alcohol. Does not take illicit drugs.
REVIEW OF SYSTEM
Constitutional: No weight loss, fever, chills, weakness or fatigue.
Skin: no rashes, no itching, no hair changes or hair loss, no nail changes.
HEENT: no headache, no vertigo, no lightheadedness; no blurring of vision, no double vision no tearing; no sore throat; no ear discharge, no ringing in the ears, no ear pain, no neck stiffness or pain.
Cardiovascular: no chest pain, no palpitation
Respiratory: no difficulty breathing, no cough
Gastrointestinal: no loss of appetite, no nausea, no vomiting, no changes in bowel habits
Genitourinary: no changes in urination, no pain in urination.
Neurologic: no difficulties with speech, memory and motor coordination; no numbness or tingling sensation
Musculoskeletal: no muscle aches, no pain or tenderness of the joints, no muscular weakness or cramps. Denies back pain at this time.
Hematologic: No anemia, bleeding or bruising.
Lymphatics: No lymphadenopathy
Psychiatric: No change in mood or orientation
Endocrine: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia, No enlarged nodes.
PHYSICAL EXAMINATION
Vital Signs: BP:137/69 HR:73 RR:18 Temp: 97.1 SpO2:95% Ht.62(in) Wt.172(lb) BMI:31.46
Constitutional: Not in acute distress. Patient is ambulatory with no assistive devices.
HEENT: Normocephalic, no facial swelling noted, no scalp lesion or tenderness; No thinning of the eyebrows noted. pupils equal and reactive to light and accommodation, extraocular muscle movement intact, pink palpebral conjunctiva, present red reflex on fundoscopy; no periorbital swelling noted. no thickening/swelling of the eyelid noted. no external ear lesions, tympanic membrane is translucent with positive cone of light on both ears, no ear discharge noted; midline nasal septum, no tongue lesions noted, no swelling of the tongue noted, no gum bleeding noted; tonsils and pharyngeal walls not swollen. Throat is pink. Non-tender and freely movable bilateral posterior cervical lymphadenopathy. No supraclavicular lymphadenopathy.
Respiratory: Clear to auscultation bilaterally. normal respiratory rate and pattern with no distress, normal breath sounds with no rales, rhonchi, wheezes or rubs
Cardiovascular: Regular rhythm. Normal S1, S2 PMI normal at fifth intercostal space No heaves or thrills noted. No murmur gallops or rubs.
Gastrointestinal: Abdomen is soft, round. normo-active bowel sounds noted. non-tender upon palpation, no guarding noted.
Musculoskeletal: no cyanosis, no clubbing of the nails, no edema, pulses normal with regular rhythm. Kyphosis noted, Full range of motion in all extremities.
Neurologic: patient is awake, alert, oriented to person, place and time; speech is clear and concise, cranial nerves intact; normal muscle tone, no loss of sensation; deep tendon reflexes are 2/4, no problems with motor coordination.
ASSESSMENT
Primary Diagnosis: Osteoporosis
Osteoporosis is a skeletal disorder characterized by a loss of bone osteoid that reduces bone integrity and bone strength, predisposing to an increased risk of fracture. Osteoporosis can be caused by a variety of factors, the most common causes include aging, sex hormone deficiency, alcoholism, smoking, and high-dose glucocorticoid administration (Buttaro et al., 2017)
Differential Diagnoses:
1. Osteomalacia- Osteoporosis may be confused with osteomalacia, but in osteoporosis, the bones are porous and brittle, whereas in osteomalacia the bones are soft. This difference in bone consistency is related to the ratio of mineral to organic material. In osteoporosis, the mineral-to-collagen ratio is within the reference range, whereas in osteomalacia, the proportion of mineral composition is reduced relative to organic mineral content (Dunphy et al., 2019)
2. Primary Hyperparathyroidsm: Primary hyperparathyroidism (PHPT) is an endocrine disorder in which autonomous overproduction of parathyroid hormone (PTH) results in derangement of calcium metabolism. In approximately 80% of cases, over-production of PTH is due to a single parathyroid adenoma and, less commonly, multi-gland involvement may occur. Diagnosis occurs through testing for a concurrent elevated serum calcium level with a higher or inappropriately normal (i.e., non-suppressed) plasma PTH level. Inherited forms, affecting a minority of patients, lead to hyperfunctioning parathyroid glands. Importantly, hyperparathyroidism is rarely caused by parathyroid cancer characterized by severe hypercalcemia (Papadakis et al., 2017)
PLAN
Diagnostics:
1. Serum calcium concentration, PTH level, Thyroid-stimulating Hormone(TSH) level, 24 hour urine calcium excretion maybe the most cost effective workup for identification of secondary causes of osteoporosis among postmenopausal women. Vitamin D deficiency is very common.
2. Dual-energy x-ray absorptiometry (DXA) is used to determine the bone density of the lumbar spine, hip, and distal radius. Bone densitometry should be performed on all patients who are at risk for osteoporosis or osteomalacia, including all postmenopausal women age 65 years and older and all men age 70 years and older.
Screening:
Fracture Risk Assessment Tool (FRAX) was developed by the World Health Organization to better predict an individual’s 10-year risk of hip or other major osteoporotic fracture. It takes into consideration age, sex, ethnicity, bone mineral density, and other risk factors.
Medical Management
1. Oral Vitamin D3 (cholecalciferol) is given either as a universal supplement of 800-2000 units/day
2. A total elemental calcium intake at least 1 000 mg/day is recommended for all adults and 1200 mg/day for postmenopausal women and men older than 70 years.
3. Hormone replacement therapy
4. Biphosphates:
Oral:
1. Alendronate is administered orally once weekly as either a 70-mg standard tablet (Fosamax) or a 70-mg effervescent tablet (Binosto)
2. Risedronate (Actonel) may be given once monthly as a 150 mg tablet.
3. Ibandronate sodium (Boniva) is taken once monthly in a dose of 150 mg orally
Intravenous:
1. Zoledronate (Zometa, Reclast) is a third-generation bisphosphonate and a potent osteoclast inhibitor. It can be given every 12 months in doses of 2 – 5 mg intravenously over at least 15-30 minutes
2. Pamidronate (Aredia) can be given in doses of 30-60 mg by slow intravenous infusion in normal saline solution every 3-6 months.
5. Denosumab (Prolia, Xgeva) is a monoclonal antibody that inhibits the proliferation and maturation of preosteoclasts into mature osteoclast bone-resorbing cells. It is indicated for treatment of osteoporosis, major fragility fractures, or osteopenia with a high FRAX score in both men and women.
6. Teriparatide (Forteo, Parathar) is an analog of PTH. Teriparatide stimulates the production of new collagenous bone matrix that must be mineralized. Patients receiving teriparatide must have sufficient intake of vitamin D and calcium. When administered to patients with osteoporosis in doses of 20 meg/day subcutaneously for 2 years, teriparatide dramatically improves bone density in most bones except the distal radius.
7. Selective Estrogen Receptor Modulators
1. Raloxifene 60 mg/day orally may be taken by postmenopausal women in place of estrogen for prevention of osteoporosis
2. Bazedoxifene is a SERM that is available as a fixed-dose combination medication with conjugated estrogens (Duavee). It is FDA-approved for the prevention of osteoporosis in postmenopausal women with an intact uterus.
3. Calcitonin A nasal spray of calcitonin-salmon (Miacalcin) is available that contains 2200 units/mL in 2-mL metered-dose bottles. The usual dose is one puff (0.09 mL, 200 international units) once daily, alternating nostrils.
This patiently taking Alendronate, Vit D 50, 000 IU and Calcium with Vitamin D. Her osteoporosis is Primary or age-related osteoporosis, she has spinal stenosis and has been taking Ibuprofen 800MG PO BID PRN for back pain. She is taking simvastatin 40MG PO QHS for hyperlipidemia. Calcium Levels is normal and Vitamin D is 14 which is a little bit low. PTH and TSH are WNL.
Education:
1. Diet should be adequate in protein, total calories, calcium, and vitamin D.
2. Nonfat or low-fat milk products, calcium fortified orange juice, green leafy vegetables, corn tortillas, and canned sardines or salmon consumed with the bones are good dietary sources
3. Vitamin D, at least 800 international units/day from food, sunlight, or supplements, is necessary to enhance calcium absorption and maintain bone mass.
4. Exercise is strongly recommended to increase both bone density and strength, thereby reducing the risk of fractures due to frailty falls. Walking increases the bone density at both the spine and hip. Resistance exercise increases spine density. The patient must choose an enjoyable exercise regimen to facilitate long-term compliance.
5. Other fall prevention measures include adequate home lighting, handrails on stairs, handholds in bathrooms, and physical therapy training in fall prevention and balance exercises.
6. Patients who have weakness or balance problems must use a cane or a walker; rolling walkers should have a brake mechanism.
7. Medications that cause orthostasis, dizziness, or confusion should also be avoided.
Consult/Referral: None
Follow-up: 3 months
Papadakis, M., McPhee, S., & Rabow, M. W. (2017). Current Medical Diagnosis and Treatment (56th ed.). McGraw0Hill Co.
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