Question

Hillary is a 72-year-old female with a history of osteopenia for the past 4 years and shortness of
breath related to 42 years of smoking. She presents today with complaints of painful sexual intercourse
and a constant feeling of being cold. Upon questioning, she reports sometimes experiencing dizziness
and light-headedness upon standing from a chair. However, she never loses consciousness when
standing. She also reports a few episodes of forgetting her two grandchildren’s names in the past
several months. On evaluation of mental status using the Mini Mental State E xam (MMSE) she scores a
26. On physical e xam, she has a blood pressure of 140/89, a weight loss of 6 pounds, and a loss of a 1/2
inch from her height from the previous visit 8 months ago. She reports no discomfort in her back or
neck regions. She has no history of stroke, seizure, heart disease, or thyroid disease. Hillary did not
begin hormone therapy at any point during or after menopause by her own choosing. She did begin

taking calcium supplements during menopause and within the past 5 years began taking over-the-
counter herbal estrogen to self-treat some of her noted symptoms.

Questions:
1. What steps would you take to address Hillary’s chief complaints for today’s visit?
2. List possible labs, tests, therapeutic options, and recommendations for the patient during this visit.
3. Would you address other existing issues or would you re-evaluate at the next visit?
4. List potential areas that will be noted for continuing evaluation and possible future treatment.

Answer 1

1) What steps would you take to address Hillary’s chief complaints for today’s visit?

Hillary has been suffering from osteopenia.

• Her bone density is lower than normal.
• Severe pain
• Loss of height
• Stooped posture

2) List possible labs, tests, therapeutic options, and recommendations for the patient during this visit.

DIAGNOSTIC TESTS

i) Lab Tests

• Serum Calcium
• Vitamin D
• Thyroid hormones

ii) DEXA test

• Dual Energy X-ray Absorptiometry is used to measure bone mineral density.
• It uses X rays that have lower radiation than a typical X-ray
• Test is painless.

TREATMENT

i) Diet

• Calcium or vitamin supplement
• Non fat and low fat dairy products such as cheese, milk and yogur.
• Orange juices, breads and cereals
• Dried beans, broccoli, wild fresh water salmon and spinach

ii) Exercises

For Hillary, age related exercises can only suggesting:

• Walking
• Swimming
• Hip abductors
• Toe and heel raises
• Prone leg lifts

RECOMMENDATIONS

• Quit smoking
• Donot use alcohol as well as caffeine
• Small amount of sun exposure is necessary
• Maintaining healthy diet
• DEXA scan atleast once to look for bone loss
• Donot use medications like cortico steroids and anti convulsants

3) Would you address other existing issues or would you re-evaluate at the next visit?

Yes. She has had shortness of breath related to smoking which is one of the risk factor for osteopenia. So following advice will give:

• Quit smoking
• Use nicotine gums
• Reduce number of cigarettes while starting to quit and cease slowly.
• Join self help groups of smoking
• Attend smoking cessation programs
• Do yoga, meditation.

4. List potential areas that will be noted for continuing evaluation and possible future treatment.

• DXA scans as the gold standard for assessing BMD levels
• Check calcium and vitamin D levels
• Assess for any fracture, further reduction in height, change in posture.
• Pain in any areas of the body
• Walking difficulty
• Any other diseases like celiac disease, hyper thyroidism, anorexia nervosa, etc.