The document discusses a 72-year-old female patient presenting with low back pain who is assessed as having osteoporosis, congestive heart failure, and atrial fibrillation. Her osteoporosis is thought to be senile osteoporosis given her age, history of menopause over 25 years ago, and radiological findings. A treatment plan is proposed including calcium and vitamin D supplementation, bisphosphonate therapy, and physiotherapy to manage her low back pain and osteoporosis.
The document discusses a 72-year-old female patient presenting with low back pain who is assessed as having osteoporosis, congestive heart failure, and atrial fibrillation. Her osteoporosis is thought to be senile osteoporosis given her age, history of menopause over 25 years ago, and radiological findings. A treatment plan is proposed including calcium and vitamin D supplementation, bisphosphonate therapy, and physiotherapy to manage her low back pain and osteoporosis.
The document discusses a 72-year-old female patient presenting with low back pain who is assessed as having osteoporosis, congestive heart failure, and atrial fibrillation. Her osteoporosis is thought to be senile osteoporosis given her age, history of menopause over 25 years ago, and radiological findings. A treatment plan is proposed including calcium and vitamin D supplementation, bisphosphonate therapy, and physiotherapy to manage her low back pain and osteoporosis.
The document discusses a 72-year-old female patient presenting with low back pain who is assessed as having osteoporosis, congestive heart failure, and atrial fibrillation. Her osteoporosis is thought to be senile osteoporosis given her age, history of menopause over 25 years ago, and radiological findings. A treatment plan is proposed including calcium and vitamin D supplementation, bisphosphonate therapy, and physiotherapy to manage her low back pain and osteoporosis.
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OSTEOPOROSIS
VERRY ASWARD SAMIUN C014172178
LUTHFI THUFAIL AKMAD C014181 A.DWIKI CAHYADI YUSUF C014181
DEPARTMENT OF INTERNAL MEDICINE
RHEUMATOLOGY DIVISION 2019 PATIENT IDENTITY Name : Mrs. Hj. S Age : 72 yo Address : Makassar Religion : Islam Status marital : Married Room : PJT Medical Record : 644482 HISTORY TAKING Consult from cardiologist with Low Back Pain Chief complaint: History of low back pain was felt since 1 month ago, pressure sensation, felt continously, before pain didn’t fell better with rest and taking medicine, worsening when doing activity such as walking and sitting. There isn’t stiffness in the joint especially in the morning. History of trauma (-). But since yesterday, she felt no pain. She was consumed paracetamol 1000mg, calcium 500mg, methylcobalt 500mcg and cavit D3 routinely. HISTORY TAKING Fever (-), headache (-), cough (-), shortness of breath (-), DOE (+). No Cough, There was shortness of breath in the last 1 years ago intermittenly, shortess of breath worsened when doing activity. No abdominal pain, no vomiting. Defacation : normal Mixturation : normal There is history of valvular disease since 4 years ago, patient routinely consumed simarc 2 mg 1x1, digoksin 0,25 mg 1x1, ISDN 5mg. HISTORY TAKING History of occupation: Patient is housewife, she rarely do physical activity in the outside. History of menopause since 25 years ago. History of gravid: Patient has 4 daughters. History of trauma: Patient had have deformity in the left wrist joint because of trauma. No history of reumatic disease. PHYSICAL EXAMINATION General Description Impression : moderate illness Nutritional status : normoweight Consciousness : composmentis Vital Signs Blood pressure : 99/50 mmHg Pulse : 44 beats / min, regular Respiration : 18 times / min Axillary temperature : 36,8° C VAS : 1/10 PHYSICAL EXAMINATION Head and Neck: Pale Conjunctiva (-), Icteric (-), Cyanosis (-) No lymph enlargement and stiff at neck
Thorax : I : Symmetrical left and right, P : No tumor mass, no tenderness P : Sonor in both lung fields A : ronchi (-/-) basal bilateral, wheezing (-/-) PHYSICAL EXAMINATION Heart : I : Ictus cordis unseen P : Ictus cordis palpable at ICS V linea medioclavicularis sinistra P : Right heart border in ICS IV linea parasternalis dextra; Left heart border in ICS VI linea medioclavicularis sinistra A : Heart sound I / II pure, regular. Systolic murmur 3/6 apex Abdomen : I : Follow the motion of breath A : Peristaltic (+) normal impression P : Liver and spleen are not palpable P : Tympani (+) RHEUMATOLOGY STATUS G (Gait) : able to walk A (Arms) : deformity of wrist joint sinistra (+), Pain (-) tenderness (-), Kalor (-), Dolor (-) L (Legs) : pain (-) tenderness (-) kalor (-) dolor (-) rubor (-) limited ROM (-), strength 5, patologic refleks (-) S (spine) : tenderness (-), laseque test (-) scoliosis (-), Kifosis (-), Lordosis (-) PATIENT PROFILE ECG
PROBLEM LIST Problem Plan Diagnostic Plan Therapy 1. Low back pain ec MRI lumbosacral Paracetamol 1000mg/12hr/oral spondylolistesis lumbalis Education plan: Explaining about the Based on: disease, examination plan, management, complications, • low back pain , felt and prognosis of the disease continuously, no spread since Physiotherapy 1 month ago • Lumbasacral photo rontgen: Spondylosis lumbalisVL4-5 Problem Plan Diagnostic Plan Therapy 2. Senilis Osteoporosis BMD Calcium 500mg/24jam/oral
Problem Based on: List Cavit D3 tab/24jam/oral Zolendronat Acid infuse/ • Low back pain, age of patient intravenous/years (runs out in > 50 yo, female. Patient is housewife and rarely do 1 hour) physical activity in the outside. Education plan: • History of menopause since Explaining about the disease, 25 years ago examination plan, • Radiology findings: management, complications, Osteoporosis and prognosis of the disease Problem Plan Diagnostic Plan Therapy 3. CHF NYHA II Echocardiography According to Cardiologist:
Problem List Based on: • Short of breathness since 1 Furosemid 40 mg/24 hr/oral
years. DOE (+)
• Thorax photo rontgen: cardiomegali with dilatation aortae
4. Atrial Fibrilation Slow
Ventricular Response Based on: • PE: HeartRate:45times/minute • ECG: Supraventrikuler rhythm, HR: 56 times/minute, normoaxis. DISCUSSION DEFINITION Osteoporosis is defined as a reduction in the strength of bone that leads to an increased risk of fractures.
The World Health Organization (WHO) operationally defines
osteoporosis as a bone density that falls 2.5 standard deviations (SD) below the mean for young healthy adults of the same sex
Kasper D et al, 2015. (Harrison’s Principle of Internal Medicine, 19th ed.)
EPIDEMIOLOGY Bone loss as a result of aging and/or estrogen deficiency is the predominant pathophysiologic disorder of primary osteoporosis. In the United States, as many as 9 million adults have osteoporosis (T-score <–2.5 in either spine or hip), and an additional 48 million individuals have bone mass levels that put them at increased risk of developing osteoporosis (e.g., bone mass T-score <–1.0).
Kasper D et al, 2015. (Harrison’s Principle of Internal Medicine, 19th ed.)
EPIDEMIOLOGY The Indonesian population is expected to grow by 20% over the next four decades, from 251 million in 2013 to 300 millions in 2050. Life expectancy is likely to reach age 80 years by 2050, and 11% increase from current 72 years EPIDEMIOLOGY One of few studies on BMD levels and osteoporosis prevalence (T score <-2.5) in the Indonesian population was conducted in 2006. Results found that the prevalence of osteoporosis in women aged between 50- 80 years was 23% and between 70-80 years was 53%. In men, BMD decreases of 10-20% between the ages of 20-39 years and 70- 79 years were shown. RISK FACTOR CLASSIFICATION CLASSIFICATION Primary Osteoporosis Secondary Osteoporosis Involutional Drugs Osteoporosis Type 1 Life changes (post menopausal) Other diseases Involusional Osteoporosis Type 2 (senile osteoporosis)
Sözen T, Özışık L, Başaran NÇ. An overview and management of
osteoporosis. European Journal of Rheumatology. 2017 Osteoporosis Involutional Characteristics Type I (Post Menopause) Type II (Senile) Age 50-75 >70 Sex Ratio (F:M) 6:1 2:1 Type of bone loss Mainly trabecular Cortical and trabecular Bone turnover Accelerated Not accelerated Fracture types Vertebral, distal radius Vertebral, neck femur Parathyroid function Decreased Increased Main causes Estrogen deficiency Aging, calcium deficiency PATHOPHYSIOLOGY Menopause
↑IL-1, TNF-α, ↓ TGF-β ↓ NO Hipocalsemia IL-6, M-CSF
↑osteoclast maturation ↑bone ↑PTH resorption
Osteoporosis
Buku Ajar Ilmu Penyakit Dalam. 6th ed. 2014
PATHOPHYSIOLOGY Aging Vitamin D deficiency, ↓ Calcium absorbtion ↓ 1-a hidroksilase activity in intestine
↓ Calcium reabsorption in renal
↓ GH & IGF-1 ↓ physical ↓ estrogen
secretion activity secretion Secondary hyperparathyroidism Osteoblast function Bone turnover disturbance
Osteoporosis
Buku Ajar Ilmu Penyakit Dalam. 6th ed. 2014
DIAGNOSIS History taking & physical examination: Osteoporosis is a silent disease until the patient experiences a fracture, no spesific symptoms, no pain. Laboratory findings: needed to rule out other responsible diseases. Xray Findings: decrease of bone mass density DIAGNOSIS TREATMENT & PREVENTION THANK YOU
