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NYU Medical Grand Rounds
Clinical Vignette
Deepa Rani Nandiwada, M.D. PGY 2
November 1, 2011
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 74 year old female, presenting with repeat
hip fracture one week ago, while on
teriparatide for treatment of her
osteoporosis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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).
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Differential Diagnosis
• Osteoporosis with treatment failure in
need of further evaluation for secondary
causes including:
• Hypoparathyroidism
• Multiple myeloma
• Hypothyroidism
• Malignancy
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Osteoporosis with treatment failure now
awaiting work up for secondary causes of
osteoporosis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS