1. NYU Medical Grand Rounds Clinical Vignette Deepa Rani Nandiwada, M.D. PGY 2 November 1, 2011 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 74 year old female, presenting with repeat hip fracture one week ago, while on teriparatide for treatment of her osteoporosis. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. Patient was diagnosed with osteoporosis 10 years ago, and has been on treatment with alendronate, until recently (She self discontinued due to fear of side effects). She is still taking calcium and Vitamin D supplementation. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. She was diagnosed with ductal carcinoma in situ (estrogen receptor postive) breast cancer in 2007 and subsequently underwent lumpectomy, radiation, and anastrazole therapy. In June of 2009 she broke her hip while on bisphosphonates. T scores on repeat dexa continued to be < -3.5 at multiple sites History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. She was then started on teriparatide and her anastrazole was switched to tamoxifen in April of 2011 Patient is now presenting to clinic with repeat contralateral hip fracture while being on long term bisphosphonates, teriparatide, anstrazole then tamoxifen, calcium, and vitamin D supplementation. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Additional History Past Medical History: Hip Fracture in 2009 Multiple compression fractures Hypothyroidism Ductal carcinoma in situ - estrogen and progesterone receptor positive, her-2 neu negative Past Surgical History: Left sided lumpectomy 2007 Social History: Denies tobacco, alcohol, drug use Lives in Brooklyn with a caretaker, and now requires a walker after the hip fracture U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Additional History Family History: Non contributory Allergies: No Known Drug Allergies Medications: Tamoxifen 20mg daily Teriparatide 20mg SC daily Valsartan 80mg daily Levothyroxine 88mcg daily. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Physical Examination Vital Signs: list T:98.5 BP: 139/90 HR: 88 RR: 12 and O2 sat: 98% BMI: 29 General: thin, frail appearing, kyphotic elderly woman in no acute distress. Musculoskeletal: significant kyphosis, no scoliosis or lordosis Remainder of physical exam was within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Laboratory Findings Calcium: 9.6 (normal range 8 – 10.4) PTH: 19 pg/ml (normal range 10 -60 pg/ml) Remainder of labs were also within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Other Studies Dexa T score of -3.5 at spine ( T score of -1.5 standard deviations defines osteopenia. T score – 2.5 standard deviations defines osteoporosis). U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Osteoporosis with treatment failure in need of further evaluation for secondary causes including: Hypoparathyroidism Multiple myeloma Hypothyroidism Malignancy Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Osteoporosis with treatment failure now awaiting work up for secondary causes of osteoporosis. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS