NYU Medical Grand Rounds Clinical Vignette David Ecker MD, PGY-2 January 20, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

A 61-year-old woman presents to her primary care physician complaining of decreasing height over several years. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS The patient was in her usual state of health until nine years prior to presentation when she underwent menopause. Hormone therapy was used briefly to ameliorate menopausal symptoms during this period. One year prior to presentation, the patient suffered a mechanical fall resulting in a Colles’ fracture.

History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS DXA performed shortly after her fall revealed a bone mineral density T-score of -1.8 at the hip (normal > -1.0). The patient started taking daily calcium and vitamin D, and started taking daily walks using light wrist and ankle weights. She now notes her height is 62 inches, down from a maximum height of 65 inches.

Additional History U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Past Medical History Hypertension Hyperlipidemia Osteoarthritis Bilateral knees Past Surgical History Breast biopsy Benign Family History Mother: Dowager’s hump Social History Lifetime non-smoker Social alcohol use Denies illicit drug use

Outpatient Medications U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Hydrochlorothiazide 25mg Daily Simvastatin 10mg Daily Calcium 1500mg Daily Vitamin D 1000 IU Daily Multivitamin Daily Ibuprofen as needed Allergies: No known allergies

Physical Examination U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS General: Well-appearing woman in no acute distress Vitals: T 98.6F, BP 128/74, HR 83, RR 14 O 2 saturation: 99% on room air Height: 62 inches, Weight: 135 lbs, BMI: 24.7 Joints: Crepitus was noted bilaterally with extension of the patient’s knees The remainder of the physical exam was normal.

Studies U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS CBC: Within normal limits Basic Metabolic Panel: Within normal limits Hepatic Panel: Within normal limits Calcium: 9.4 mg/L (8.4 – 10.2 mg/L) 25-hydroxy-vitamin D: 40ng/mL ( ng/mL) Thyroid stimulating hormone: 2.61 uIU/mL (0.35 – 4.8 uIU/mL) 24-hour urinary calcium 204 mg/24h ( mg/24h)

Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Osteopenia

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Further treatment Treatment with alendronate was initiated. Follow-up DXA was scheduled.