SITUATIONAL PROBLEM K003239

1. Osteoporosis of combined genesis (postmenopausal + senile), severe course (compression fractures of the vertebral bodies in the lumbar region).

2. The diagnosis of “osteoporosis” was established on the basis of the patient’s typical complaints (pain of a constant nature, aggravated by exertion in the lumbar spine), anamnesis of the disease (the onset of pain in old age after intense physical exertion), the presence of risk factors (early surgical menopause), data examination (strengthened thoracic kyphosis, smoothed lumbar lordosis) and X-ray examination (wedge-shaped deformity of the vertebral bodies).

The diagnosis of “arterial hypertension” was established based on the anamnesis data.

3. The patient is recommended:

performing dual-energy x-ray bone absorptiometry (DXA) to assess bone mineral density. This technique is necessary not only to confirm the diagnosis, but also to dynamically assess and monitor the effectiveness of the therapy;

determination of the absolute risk of fractures over the next 10 years of life using the FRAX calculator. The indication for the start of treatment is the risk of total fractures – more than 20%, the risk of hip fracture – more than 3%;

a study of total calcium and phosphorus in the blood serum to identify contraindications to treatment or correction of disorders (hyperparathyroidism, bone disease).

According to indications, it is possible to determine the level of PTH (suspected hyperparathyroidism), 25 (OH) D3 (if hypovitaminosis D is suspected), Ca and creatinine in morning and daily urine, creatinine clearance and TSH in women (identifying the causes of secondary osteoporosis). In addition, the patient is shown consultations of related specialists – an ophthalmologist and a neurologist – to identify disorders that can increase the risk of falls and correct them.

4. It is advisable to include in the management plan of this patient not only methods of treatment to increase bone density, but also methods of prevention to reduce the risk of fractures.

Of the methods of prevention, the most important is:

physiotherapy exercises to strengthen muscles and improve muscle feeling (reducing the risk of falls);

patient education, namely, explaining behavior at home and on the street in order to reduce the risk of falls;

identification of concomitant diseases that may be accompanied by imbalance.

The methods of non-drug treatment should include the use of a corset: in the first 8 weeks, it is necessary to use a rigid frame corset (with limited movements in the spine), later – a dynamic corset.

Of the medical methods should be used:

calcium and vitamin D preparations in the following doses: calcium – 1200 mg / day, vitamin D

– 1000-2000 IU / day; several groups can be used as anti-osteoporotic drugs: bisphosphonates (alendronate at a dose of 70 mg/week, ibandronate at a dose of 150 mg/month, risedronate at a dose of 35 mg/week, zoledronic acid at a dose of 5 mg/year), denosumab at a dose of 60 mg – 1 time in six months. Taking into account the presence of a compression fracture

salmon calcitonin 200 IU intranasally or 100 IU IM for 2 weeks may be offered.

5. It should be clarified with the patient how accurately she followed all the doctor’s prescriptions (dose and frequency of taking the drugs). If all appointments were carried out in full, additional examination should be carried out to exclude metabolic diseases of the skeleton – determination of the level of calcium, phosphorus and vitamin D in the blood serum, parathyroid hormone, TSH alkaline phosphatase and refer for a consultation with a rheumatologist. In the absence of other metabolic diseases of the skeleton, it is possible to prescribe Denosumab, or Teriparatide, or Strontium ranelate in combination with calcium and vitamin D preparations and conduct control densitometry after 1 year.

CASE STUDY 54 [K003241]

Instructions: READ THE SITUATION AND GIVE DETAILED ANSWERS TO THE QUESTIONS

Main part

A 42-year-old woman, a manager, came to the appointment with complaints of pain and swelling in the II-IV proximal interphalangeal joints, II-III metacarpophalangeal joints, wrist, knee joints; morning stiffness in these joints until the middle of the day; weight loss by 4 kg in the last 2 months, weakness. Upon additional questioning, she notes that she began to endure physical activity worse: when climbing to the 3rd-4th floor, shortness of breath and palpitations appear. Indicates that due to pain and stiffness in the joints, she became less able to cope with professional duties.

The patient considers himself within six months, when these symptoms first appeared and gradually progressed. She did not go to the doctors, tried to rest more, took analgin irregularly, without a significant effect. The condition worsened in the last two months, when the pain in the joints increased significantly, stiffness, weight loss appeared, then weakness and palpitations. On the advice of a neighbor, she took aspirin, diclofenac (in the last 1.5 months – daily), with a slight positive effect.

On examination: the condition is satisfactory, the position is active, the temperature is 36.4°C. The skin is pale, dry. Height – 168 cm, weight – 54 kg, BMI – 19.1 kg / m2. When examining the musculoskeletal system II-IV, the proximal interphalangeal, II-III metacarpophalangeal joints, wrist, knee joints are edematous, painful on palpation, movements in them are limited. The balloting of the patella is determined, the retraction of the interosseous spaces on both hands. Number of Painful Joints (NJs)

– 12, the number of swollen joints (SJS) – 10. Vesicular breathing in the lungs, no wheezing. BH – 16 per minute. The heart sounds are clear, the rhythm is correct, the heart rate is 104 per minute. BP – 120/80 mm Hg. The tongue is not coated, wet. The abdomen is of normal size and shape, participates in breathing, painless on palpation. The liver is 9(0)×8×7 cm. The spleen is not enlarged. Tapping on the lumbar region is painless. The chair is designed 1 time per day, without pathological impurities. Urination 4-5 times a day, no dysuria. Complete blood count: erythrocytes – 3.3 × 1012 / l, hemoglobin – 95 g / l, MSI – 24 pg, MCV – 75 fl, leukocytes – 7.9 × 109 / l, basophils – 0%, eosinophils – 2% , segmented neutrophils – 69%, lymphocytes – 18%, monocytes – 11%, platelets – 392×109/l, ESR – 35 mm/hour.

General analysis of urine: transparent, specific gravity – 1010, reaction – slightly acidic, protein and sugar – absent, flat epithelium – 4-6 in the field of view, leukocytes – 3-5 in the field of view, erythrocytes, bacteria – absent.

Biochemical blood test: glucose – 4.8 mmol / l, creatinine – 85 μmol / l, GFR – 68 ml / min, bilirubin – 14.5 μmol / l, AST – 24 IU / l, ALT – 30 IU / l, uric acid – 224 µmol/l, PSA – 30.5 mg/l.

RF – 120 IU/l, antinuclear factor – negative. The overall self-assessment of health by the patient is 56 mm on the VAS scale.

X-ray of the hands and feet: periarticular osteoporosis, mainly in II-IV proximal interphalangeal, II-III metacarpophalangeal joints.

Questions:

1. Suggest the most likely diagnosis.

2. Justify your diagnosis.

3. Draw up and justify a plan for an additional examination of the patient.

4. What symptomatic drugs would you prescribe to the patient within 5-7 days before receiving the results of the additional examination (with indication of the dose and frequency of administration)? Justify your choice.

5. The patient was further examined: serum iron – 6 µmol/l, TIBC – 58 µmol/l, ferritin – 115 ng/ml, vitamin B12 – 450 ng/ml, folic acid – 45 ng/ml, Zimnitsky’s test – no pathology, daily proteinuria – negative, on FGDS – hernia of the esophageal opening of the diaphragm of the 1st degree, chronic gastritis; on fluorography of the lungs without pathology; examination by a gynecologist – without pathology. Determine further management of this patient. Justify your choice.

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