1. As She Suffers From

1. As she suffers from osteoporosis, several mechanisms are at play in Mrs. Wood's condition. The basic elements result from poor bone mass accumulation during childhood combined with an acceleration of bone loss adulthood, when peak bone mass has been achieved. One half of bone mass is made during pre-puberty, with only minimal accumulation of minerals in the teens and peak bone mass in the 20s. Mrs. Wood's rate of bone loss is based more upon her lifestyle than her genes. Dietary calcium, vitamin D, protein and calories impact on her development of osteoporosis. If she had poor calcium intake in her childhood, this directly impacts her likelihood of fracture in adulthood (Heaney, 1998). Mrs. Wood's calcium intake is directly associated with bone mineral mass at any age. Supplementation reduces the rate of bone loss and will reduce her risk of fracture. Vitamin D intake is necessary for bone mineral metabolism and the rate of osteoclastic resorption. The addition of Vitamin D to calcium supplementation reduces fracture rates. Other elements in Mrs. Wood's diet impact on her osteoporosis. The degree of protein and caloric intake in her daily diet will support fat and muscle that is covering bony areas. There are several medications which may be associated with the development in osteoporosis for Mrs. Woods. Chronic steroid use may have contributed to her condition, resulting in the loss of trabecular bone mass. It is estimated that 20-40% of bone loss occurs within the first year of steroid use, especially in patients using doses greater than 7.5 mg per day (Libinat and Baylinki, 1997). The most common sign of osteoporosis is a skeletal fracture, and the most common fracture will be seen in the vertebral column. Mrs. Woods may remain completely asymptomatic even after compression fracture has occurred. These usually happen in the course of the day with normal activity. A cough or working in the garden is enough to cause a vertebral compression fracture in the lumbar spine of a patient with osteoporosis. Mrs. Woods may be asymptomatic, as noted, or she may note an acute episode of back pain which resolves or becomes more chronic and dull in nature. Should Mrs. Wood experience multiple vertebral compression fractures, she may note a loss in height and eventual development of a Dowager's hump, as is called the thoracic kyphosis resulting from the fracture. She may find that her clothes no longer fit as they did before, she may notice a thickening in the area of her waist, primarily because the vertical dimension of the abdominal cavity disappears secondary to the vertebral collapse and the abdominal contents shift toward the anterior region (Kanis, 1994; Wasnich, 1993). Mrs. Woods may notice this causes a new and very slow onset of shortness of breath because of the reduction in thoracic volumes and poor lung volumes due to thoracic restriction. Hip fracture after falls is also very common in patients who have osteoporosis. Mrs. Wood may also note leg cramps, bone pain and tenderness (not necessarily in the joints), abdominal pain, rib pain, tooth loss and periodontal disease, fatigue and brittle fingernails. Pain and fractures in joints are not always secondary to falls, but may occur due to subchondral insufficiency in femoral head fractures. Another common injury in patients who have osteoporosis is a Colles' fracture, in which there is a fracture of the distal radius after the most minimal trauma. This often occurs when the patient falls or trips and catches oneself against an outstretched hand. 2. Mrs. Woods, I am sure you are concerned about the symptoms you have been experiencing. It appears from your x-rays that you have developed a condition which is called osteoporosis. Have you ever heard of this condition before, or do any of your friends have this condition? Well, osteo means related to the bone, and porosis is just as it sounds, your bones are a little bit more porous and brittle appearing on the x-rays than would perhaps be seen in a younger patient, or in a patient who does not have osteoporosis. The cells which break down your bones are working a little harder than the cells which build up your bones. While this can be seen in some degree in all patients over age 50, in your case we are seeing a little bit more of it than we would like, and as a result you are having these symptoms. Osteoporosis can cause your bones to be brittle and break more easily, so perhaps if you were to have a fall that would not have caused more than a bruise in the past, you will now have to take care that you observe that you have not caused a break in your bones. This can sometimes cause quite a bit of pain, but in other patients only cause a bit of a dull ache. In any case, when you have a fall or pain, we would want you to come in so an x-ray could be done to make sure you have not done any damage. The doctor and the medical team want you in the hospital right now so we can take a look at your bones, see what degree of osteoporosis is there, and perhaps even begin treatment. Luckily, there are some things that we can do to make you feel better and improve the health of your bones. We will also be talking about some things in your past, such as medicines you have taken, which may have contributed to this condition (Nolan, Davies, & Grant, 2001). 3. Education will be key to Mrs. Wood's recovery, since we cannot reverse the osteoporosis which has already occurred. We may, however, be able to preserve the healthy bone mineral mass she still has and for that reason it would be good to have the pharmacist come in to speak to Mrs. Woods about some medications which may be helpful in treating her disease. The pharmacist will discuss some nutritional supplements which will be helpful in preserving bone mass as well as medications which may help build the bone she has already (Gray, et.al, 2000) . Additionally, Mrs. Woods would do well to see the nutritionist. While medication and nutritional supplementation will be helpful to her condition, there are certain dietary choices she could make which would be healthier for her, like dairy foods which are higher in calcium as well as green vegetables which have calcium, especially if she has developed an element of lactose intolerance as do many older patients. The nutritionist will also be able to identify elements in her diet which are not good for bone health, like high caffeine intake or alcohol. Finally, it would be good for Mrs. Woods to see a physiotherapist. Her pain from previous fractures may cause her to limit her range of motion and activity, which will in turn complicate her osteoporosis. It would be helpful were she to be instructed on physical exercise which will help her maintaining range of motion to keep her joints flexible and maintain her vertebral height as much as possible. Weight bearing exercise would also modify the degree to which she experiences ongoing bone loss. A physiotherapist would instruct her to be careful to follow an exercise regimen which will be good for her and not cause a greater degree of trabecular bone loss or deformation of her articular cartilage. 4. The physician would help in arranging for coordination of care for Mrs. Woods. He or she will order bone mineral density testing to evaluate the degree of bone loss, as well as metabolic testing to ensure 1) there is not another physical condition which is causing her bone loss and 2) there is no physical condition which would prevent her from taking some of the medications she would need to treat her osteoporosis. I am thinking specifically of issues such as hyperparathyroidism, history of renal calculi and liver disease, a history of dysphagia or esophageal erosions. The nursing staff will ensure that Mrs. Woods is clear regarding all the testing and the results, and that she has a clear idea of the treatment plan. It is also important that Mrs. Woods feels comfortable with the treatment plan and understands what and why things are being done. A pharmacist will evaluate the testing ordered by the physician and give opinion on which medications, if any, would be helpful for treating Mrs. Woods' condition. Additionally, the pharmacist can give Mrs. Woods advice regarding the timing of the medication administration and side effects she should be aware of. A physiotherapist can set up an exercise plan for Mrs. Woods to ensure she gets the appropriate type and amount of exercise to treat her condition. The physiotherapist would be aware of possible co morbid factors which would limit Mrs. Woods' exercise ability. A social worker could evaluate Mrs. Woods' home situation to see if any assistance would be needed regarding activities of daily living or transportation needs. Additionally, the social worker may be able to set Mrs. Woods up with an exercise group close to her house, or a support group who could help her with adjusting to her new diagnosis and give her support. The social worker and the nursing staff would also be able to educate Mrs. Woods' family on the condition and what needs to be done to maximize her bone health. 5. Should Mrs. Woods have a history of renal calculi; care will be taken for the administration of calcium supplements. Any supplement she would take would need co-administration of Vitamin D for proper absorption. Hormone replacement therapy is no longer considered to be a stable of treatment due to concerns about heart disease. Additionally, there was no significant evidence of fracture reduction of the HERS study, so the risk of thrombosis and breast cancer probably outweighs the need for HRT. Selective estrogen receptor modifiers are other alternatives which preserve bone density but do not affect the endometrium or the breast tissue. These medications two years show a modest increase in bone mineral density but there has been evidence of an increased incidence of thromoembolic disease.