Musculoskeletal

Patient Profile

Name: Mrs. Cheryl Bennett

Age: 72 years old

Gender: female

History of Present Illness

C.B. is a 72-year-old woman who presents to the clinic with persistent lower back pain that began after a minor fall at home two weeks ago. She describes the pain as dull and constant, with occasional sharp exacerbations when bending or twisting. She denies significant trauma but is concerned about her bone health, as she has noticed a gradual loss of height over the past few years and increasing difficulty maintaining her posture. She also reports a recent onset of fatigue and difficulty walking long distances due to back discomfort. Mrs. Bennett mentions that she has been feeling more unsteady on her feet and has had two near-falls in the past month. She denies numbness, tingling, or weakness in her legs. She has occasional stress incontinence at baseline and has a bowel movement without difficulty daily or every other day. She reports normal genital and buttock sensation when sitting on the toilet and wiping. She denies any bowel or bladder changes since the fall. Additionally, she reports that her clothing no longer fits as it used to, particularly around the waist, which she attributes to her “shrinking height.” She is worried about her risk of fractures, especially since her mother suffered a hip fracture at a similar age. Mrs. Bennett also notes that she has been experiencing mild muscle cramps in her legs, which she attributes to her calcium supplements.

Past Medical History

• Menstrual History: Menopause at age 50, no hormone replacement therapy.
• Dietary History: Low dairy intake throughout her life; relies on supplements for calcium and vitamin D.
• Lifestyle: Sedentary lifestyle with minimal weight-bearing exercise. She spends most of her day sitting or lying down due to back pain. She denies smoking but drinks one glass of wine daily.
• Fall History: Minor fall two weeks ago while reaching for an object on a high shelf. No significant trauma, but persistent back pain since then. Two near-falls in the past month due to feeling unsteady.
• Fracture History: Distal radius fracture at age 68 after tripping on a rug.
• Musculoskeletal: Persistent lower back pain, height loss, kyphosis, and mild leg cramps.
• Neurological: No numbness, tingling, or weakness while standing or sitting.
• Gastrointestinal: No changes in bowel habits or appetite.

Current Medications

• Calcium and Vitamin D supplements, Hydrochlorothiazide, Acetaminophen PRN for osteoarthritis

Family History

Mother had a hip fracture at age 75 and was diagnosed with osteoporosis. No other significant family history of bone or metabolic disorders.

Physical Assessment

• General Appearance: Thin, frail-appearing elderly woman with a noticeable kyphotic posture.
• Height and Weight: Height: 5’2″ (previously recorded as 5’4″ five years ago), Weight: 110 lbs, BMI: 20.1.
• Spinal Examination:
  • Tenderness over the thoracic and lumbar spine, particularly at T8 and T10.
  • Kyphosis with reduced spinal flexibility.
  • Reflexes: +2 bilaterally in lower extremities.
    • Saddle sensation intact.
• Musculoskeletal Examination:
  • Decreased grip strength bilaterally.
  • No joint swelling or erythema.
• Gait and Balance:
  • Slightly unsteady gait with reduced stride length.
  • Negative Romberg test.
• Skin and Nails: Normal, no signs of bruising or petechiae.

Diagnostic Assessment

• Vitamin D (25-hydroxyvitamin D):
  • Result: 18 ng/mL (deficient; normal range: ≥30 ng/mL)
  • Interpretation: Indicates vitamin D deficiency, common in osteoporosis. Vitamin D deficiency impairs calcium absorption, leading to secondary hyperparathyroidism, which increases bone resorption to maintain normal serum calcium levels.
• Serum Calcium:
  • Result: 9.2 mg/dL (normal; normal range: 8.5–10.2 mg/dL)
  • Interpretation: Normal calcium levels are maintained due to increased bone resorption, compensating for low dietary calcium or vitamin D deficiency. Calcium is a critical component of hydroxyapatite, the mineralized structure in bone, and is essential for bone remodeling and repair following fractures. It provides the building blocks for new bone formation and helps prevent further bone loss.
• Serum Phosphorus:
  • Result: 3.4 mg/dL (normal; normal range: 2.5–4.5 mg/dL)
  • Interpretation: Normal phosphorus levels are typical in osteoporosis but may be altered in other conditions like osteomalacia or hyperparathyroidism.
• Parathyroid Hormone (PTH):
  • Result: 75 pg/mL (elevated; normal range: 10–65 pg/mL)
  • Interpretation: Elevated PTH suggests secondary hyperparathyroidism due to vitamin D deficiency, which increases bone resorption to maintain serum calcium levels.
• Serum and Urine Protein Electrophoresis:
  • Result: Normal
  • Interpretation: Rules out multiple myeloma as a cause of bone pain or fractures.
• Alkaline Phosphatase:
  • Result: 85 U/L (normal; normal range: 44–147 U/L)
  • Interpretation: Normal alkaline phosphatase levels are consistent with osteoporosis. Elevated levels would suggest increased bone turnover, as seen in osteomalacia or Paget’s disease.

Imaging Study Results

• Dual-energy X-ray Absorptiometry (DXA):
  • Result: T-score of -2.9 at the lumbar spine and -2.7 at the femoral neck.
  • Interpretation: T-scores ≤ -2.5 confirm a diagnosis of osteoporosis. A score of -1 to -2.5 is osteopenia. -1 or greater is considered normal density.
• X-ray of the Spine:
  • Result: Evidence of vertebral compression fractures at T8 and T10.
  • Interpretation: Shows anterior wedging of vertebrae, consistent with osteoporotic fractures. In osteoporosis, trabecular bone undergoes thinning and loss of its interconnected structure, making it more prone to vertebral compression fractures. No lytic or blastic lesions are present, ruling out malignancy.
• Vertebral Fracture Assessment (VFA):
  • Result: Confirms asymptomatic compression fractures at T7 and T9 in addition to symptomatic fractures at T8 and T10.
  • Interpretation: Identifies additional vertebral fractures that may not have been clinically apparent, which is common in osteoporosis.

Diagnosis

• Vitamin D Deficiency with Secondary Hyperparathyroidism
• Osteoporosis with multiple vertebral compression fractures consistent with the clinical presentation of a postmenopausal woman with low bone density and fragility fractures.