Overview Snapshot A 67-year-old woman presents to the emergency department after falling while walking down the stairs of her home. She landed on her rear on a carpeted floor and denies hitting her head. She experienced severe pain in her right hip after the fall and is unable to bear weight on the affected side. Menopause began 17 years ago. She has smoked 1-pack of cigarettes for the past 40 years. On physical exam, her right leg is shortened, adducted, and externally rotated. Laboratory testing is unremarkable. Introduction Clinical definition decreased bone mass (osteopenia) that significantly increases the patient's risk of fracture Epidemiology incidence most common types of osteoporosis are post-menopausal senile risk factors post-menopausal women being ≥ 65 years of age people of Caucasian and Asian descent lifestyle factors such as poor physical activity vitamin D deficiency and poor calcium intake smoking alcohol use disorder medications such as warfarin, lithium, proton pump inhibitors, and glucocorticoids hyperparathyroidism hyperthyroidism multiple myeloma malabsorption syndromes Pathogenesis in young adulthood, peak bone mass is achieved and this is determined by a number of factors (e.g., genetics) after this peak bone mass is attained, there is a small decrease in bone formation with every cycle of bone remodeling senile osteoporosis osteoblasts have their biosynthetic and proliferative ability reduced with age poor physical activity mechanical force on bone stimulates bone remodeling athletes have increased bone density decreased physical activity results in bone loss decreased estrogen levels such as in menopause, decreased estrogen levels increase bone resportion and formation however, the rate of formation is less than resorption resulting in a net bone loss increased osteoclast activity is significant in areas of bone with large surface area such as the vertebral bodies, leading to vertebral compression fractures there is trabecular and cortical bone loss Prognosis generally good if detected early and appropriately managed Presentation Symptoms fractures (e.g., vertberal and hip), otherwise, patients are typically asymptomatic Physical exam may see loss in height Imaging DEXA indication all women ≥ 65 and all men ≥ 70 years of age smoking and sedentary lifestyles are risk factors notes T-score ≤ -2.5 Studies Labs serum calcium, phosphorus, parathyroid hormone, and alkaline phosphatase are normal Histology histologically normal; however, there is a decreased quantity of normal bone Differential Laboratory Abnormalities in Select Bone Disorders Etiology Serum Phosphate Serum Calcium Serum Alkaline Phosphatase Parathyroid Hormone Osteomalacia / rickets Decreased Decreased Increased Increased Osteoporosis Normal Normal Normal Normal Osteopetrosis Normal Normal or decreased Normal Normal Paget disease of the bone Normal Normal Elevated Normal Osteitis fibrosa cystica Primary • hyperparathyroidism- decreasedSecondary• hyperparathyroidismincreased Primary • hyperparathyroidismincreasedSecondary• hyperparathyroidismdecreased Primary and secondary hyperparathyroidism increased Primary and secondary hyperparathyroidism increased Hypervitaminosis D Increased Increased Normal Decreased Treatment Conservative calcium and vitamin D supplementation strength training smoking cessation Medical bisphosphonates indication first-line for pharmacologic therapy in osteoporosis raloxifene second line therapy for osteoporosis can cause hot flashes and venous thromboembolism does not cause endometrial hyperplasia or increase risk of breast cancer teriparatide indication considered first-line in patients with a very high risk of fracture Complications Fractures
QUESTIONS 1 of 6 1 2 3 4 5 6 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.OR.4754) A 64-year-old female presents to her primary care physician for an annual checkup. She states that her health is adequate, but she has not been doing well since her husband died last year. She is able to get by but admits to having trouble caring for herself, cooking, cleaning, and paying her bills. The patient complains of diffuse muscle aches and pains. She has a past medical history of anxiety and seasonal affective disorder. She is not currently taking any medications. On physical exam, you note a gaunt woman with a depressed affect. You note that her body mass index (BMI) and height have both decreased since her last annual visit. On physical exam, her cardiac, pulmonary, and abdominal exams are within normal limits. Lab work is drawn and is as follows:Serum:Na+: 135 mEq/LK+: 3.7 mEq/LCl-: 100 mEq/LHCO3-: 23 mEq/LUrea nitrogen: 7 mg/dLGlucose: 70 mg/dLCreatinine: 0.8 mg/dLCa2+: 8.0 mg/dLMg2+: 1.5 mEq/LParathyroid hormone: 855 pg/mLAlkaline phosphatase: 135 U/LPhosphorus: 2.6 mg/dL Hemoglobin: 14 g/dLHematocrit: 36%Platelet count: 187,000/mm^3Leukocyte count: 4,700/mm^3What is the most likely diagnosis? Review Topic | Tested Concept QID: 108976 Type & Select Correct Answer 1 Osteopenia 4% (2/45) 2 Osteoporosis 7% (3/45) 3 Osteomalacia 47% (21/45) 4 Hyperparathyroidism 27% (12/45) 5 Clinical malnutrition 9% (4/45) M2 D Tested Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.OR.37) A 67-year-old Caucasian female presents to her primary care physician after a screening DEXA scan reveals a T-score of -3.0. Laboratory work-up reveals normal serum calcium, phosphate, vitamin D, and PTH levels. She smokes 1-2 cigarettes per day. Which of the following measures would have reduced this patient's risk of developing osteoporosis? Review Topic | Tested Concept QID: 102978 Type & Select Correct Answer 1 Reduced physical activity to decrease the chance of a fall 0% (0/12) 2 Initiating a swimming exercise program three days per week 75% (9/12) 3 Intranasal calcitonin therapy 0% (0/12) 4 Calcium and vitamin D supplementation 17% (2/12) 5 Weight loss 0% (0/12) M2 C Core Select Answer to see Preferred Response SUBMIT RESPONSE 4 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M3.OR.10) A 47-year-old African-American woman presents to her primary care physician for a general checkup appointment. She works as a middle school teacher and has a 25 pack-year smoking history. She has a body mass index (BMI) of 22 kg/m^2 and is a vegetarian. Her last menstrual period was 1 week ago. Her current medications include oral contraceptive pills. Which of the following is a risk factor for osteoporosis in this patient? Review Topic | Tested Concept QID: 102951 Type & Select Correct Answer 1 Age 0% (0/2) 2 Body mass index 0% (0/2) 3 Estrogen therapy 0% (0/2) 4 Race 0% (0/2) 5 Smoking history 100% (2/2) M2 D Tested Select Answer to see Preferred Response SUBMIT RESPONSE 5