Question

M.S., a 72-year-old Caucasian female, comes to your clinic for a complete physical examination. She has not been to a provider for 11 years because “I don't like doctors.” Her only complaint today is “pain in my upper back.” She describes the pain as sharp and knifelike. The pain began approximately 3 weeks ago when she was getting out of bed in the morning and hasn't changed at all. M.S. rates her pain as 6 on a 0- to 10-point pain scale and says the pain decreases to 3 or 4 after taking “a couple of ibuprofen.” She denies recent falls or trauma.

M.S. admits she needs to quit smoking, lose some weight, and start exercising but states, “I don't have the energy to exercise.” She has smoked 1 to 2 packs of cigarettes per day since she was 17 years old. Her last blood work was 11 years ago, and she can't remember the results. She went through menopause at the age of 47 and has never taken hormone replacement therapy. The physical exam was unremarkable other than moderate tenderness to deep palpation over the spinous process at T7. No masses or tenderness to the tissue surrounded the tender spot. No visible masses, skin changes, or erythema were noted. Her neurologic exam is intact, and no muscle wasting is noted. M.S. has never had osteoporosis screening. She confides that her mother and grandmother were diagnosed with osteoporosis when they were in their early 50s.

1. An x-ray examination of the thoracic spine reveals osteopenic changes at T7. The physician suspects osteoporosis. List five risk factors associated with osteoporosis.
2. Later, M.S.'s DEXA scan revealed a bone density of −2.6 SD (standard deviations). What does this mean?
3. The physician orders alendronate (Fosamax) 70 mg/wk. What instructions should you give M.S. regarding alendronate?
4. What nonpharmacologic interventions should you teach M.S. to prevent further bone loss?
5. M.S. seems overwhelmed and says, “I cannot possibly stop smoking and lose weight and exercise all at the same time.” You encourage M.S. to start working on one problem at a time. Which problem should M.S. attempt first?

Answer 1

●The risk factors associated with osteoporosis are

• Excessive body weight
• Family history
• Medication (Ibuprofen)
• Smoking
• Menopause
• Lack of exercise

●The DEXA is a diagnostic test to rule out osteoporosis. The normal range should lie between +1to -1,the low bone mass ranges from -1 to -2.5, and when it is above -2.5SD it is osteoporosis. Here the patient value is -2.6 SD means a diagnosis of osteoporosis.

●The following patient education should be given to the patient

• Take the medication early in the morning after getting up in empty stomach for maximum absorption
• Do not take any other medications with are immediately after taking Fosamax ,with for at least 30 minutes
• Take the medication in a sitting position, so that the medication when swallowed doesn't irritates the esophagus while passing
• Take with a full glass of water ,no other substitutes
• Do not lie immediately after taking medication, wait for at least 30 minutes
• Do not overdose or under dose
• No OTC medications
• Report any side effects immediately

●Some of the nonpharmacological intervention are

• Diet rich in calcium,vitamins, minerals like milk and its products, vegetables, fruits ,nuts ,etc.,
• Regular walking daily to manage weight

research says quitting smoking a month can be effective for an individual to quit it for another five months but people on weight reduction tends to manage it for one year only.In simple smoking cessation is a one time decision where weight management lies daily on what we eat and what to avoid .So it is best to stop smoking gradually first and then working on weight management.