OSTEOPOROSIS

MUSHLIH ANDRI KHAIRYAWAN

SRI NURCAHYANI ISKANDAR
NURFAIDAH
NURUL NAINEYAH

Adviser : dr. ITA PUSPITA DEWI

 PATIENT IDENTITY

Name : Mr. S
Age : 62 years old
Occupation : Ex-Government Employee
Religion : Moslem
Ethnic : Makassar
Marital Status : Married
 HISTORY TAKING
Chief complaint : Pain in both of knees

Patient admitted to the hospital with chief complaints is pain in

both of knee, since 2 years ago. The pain felt worse in last 1 week
at right knee. It felt when the knee is moving, there is no morning
stiffness, it can't released by rest. The pain doesnt radiated.
Patient had difficulties to walk due to pain.
 HISTORY TAKING

- No fever, no cough
- No nausea and vomiting
- Defecation: normal
- Urination: normal, yellow color.
- No history of DM and hypertension
- No history of long-term corticosteroid intake.
- No history of smoking and alcohol consumption
- No history of trauma. No history of lifting heavy weight.
 PHYSICAL EXAMINATION
General Description
General condition : Moderate illness
Nutritional status : 87,7% (normal)

Vital Signs
Consciousness : Compos mentis (GCS 15 E4M6V5)
Blood pressure : 130/80 mmHg
Heart rate : 80 x/ min regular
Respiratory rate : 16 x/min
Temperature : 36,5C (axilla)
VAS : 4/10
 PHYSICAL EXAMINATION
Head : Normocephal

Face : Normal

Eyes : Isocor pupils, normal light reflex, no icteric schlera, no pale

conjunctiva

Ear : No abnormalities, otorrhea (-)

Nose : No abnormalities, epistaxis (-)

Lips : No abnormalities, cyanosis (-)

Oral cavity : No abnormalities, gingival hypertrophy (-), oral trush (-)

Throat : No abnormalities, pharyngeal hyperemia (-), T1-T1 normal

Neck : JVP R +1 cmH2O, no lymphadenopathy

 PHYSICAL EXAMINATION
Lung
Inspection : Symmetrical left and right
Palpation : No mass, normal tactile fremitus
Percussion : Sonor
Auscultation : Vesicular breathing sounds, no ronchi, no wheezing
Heart
Inspection : Ictus cordis unseen
Palpation : Ictus cordis palpable on ICS V linea midclavicula
Percussion : Dull, left heart border 1 finger laterally from left
linea midclavicularis
Auscultation : heart sound I / II regular, no murmur

Abdomen
Inspection : Flat
Auscultation : Bowel peristaltic (+) normal
Palpation : No ascites, no organomegaly
Percussion : Tympani
 RHEUMATOLOGICAL STATUS

Gait : Antalgic gait

Arm : Normal
Leg :
Genu (D) : kalor (-), dolor (-), rubor (-), crepitation (+),
effusion (-), limited ROM (+), oedem (+)
Genu (S) : kalor (-), dolor (-), rubor (-), crepitation (+),
effusion (-), limited ROM (+), oedem (-)
Spine : Normal
 LABORATORY FINDING

WBC : 10,42
Ur : 16
HGB : 10,1
Cr : 0,65
PLT : 441

GOT : 16 Na/K : 139/3.2

GPT :8
 X-ray Genu D et S AP/Lat
Osteoarthritis
Osteoporosis senile
Assessment Planning Diagnostic Planning Therapy

Problem List
1. Osteoartritis genu bilateral
Based on :
ESR - Meloxicam 7,5 mg/

- Pain of the knee Uric acid 24hrs/oral

- Crepitus - Omeprazole 20 mg/24 hrs/
- >50 years old
oral
- X-Ray Genu : Osteoartritis

- Rest of the knee joint

2. Osteoporosis Vit D and calcium Cavit D3 1tab/24hr/oral

Based on: serum
Age 62 years old Bone mass Zolendronic Acid/IV
X-Ray Genu : signs of osteoporosis densitometry
senilis
DISCUSSION
 DEFINITION
Osteoporosis is a disease marked by reduced bone
strength leading to an increase of fracture that occur
following minimal trauma (pathologic fracture) or in
some case with no trauma.
Bone strength has 2 main feature :
Bone mass (amount of bone)
Bone quality
 EPIDEMIOLOGY
In the US (2016), more 53 million peoples either already have
osteoporosis or are at high risk due to low bone mass.
Osteoporosis can occur at any age(although, the risk for
developing disease increase as the person gets older)
Affects 18-28% of women and 6-22% of men over the age of
50 years old
Half of all postmenopausal women and a quarter of men over
50 years old will have an osteoporosis related fracture

Based on patients
condition:
1. 62 years old (>50
years old)
 CLASSIFICATION OF
OSTEOPOROSIS
Osteoporosis is divide into 3 Categories: Primary, Secondary, and Idiopathic

Primary Osteoporosis is osteoporosis that occurred in every ages group. divide

into Type I and Type II
Type I : Postmenopausal Osteoporosis
Type II : Senile Osteoporosis
Secondary Osteoporosis
An Osteoporosis that caused by an underlying disease, some drugs effect, etc.
Idiopathic Osteoporosis
An osteoporosis that occurred in juvenile, adolescent, or middle ages that caused by
an unknown condition.
Based on patients condition,
can be classificate to type II
Primary Osteoporosis
Source: Canalis, et.al. Osteoporosis Int 2007 in dr. Faridins Slide
RISK FACTOR
 CLINICAL Patients who have sustained a vertebral
compression fracture may note progressive
FINDINGS kyphosis with loss of height. They may also

Generally patients are asymptomatic
even with very low bone densities
Hip Fractures
Acute or chronic back pain secondary
to vertebral fractures
Atraumatic or low impact fractures
present with an episode of acute back pain
after bending, lifting, or coughing. It should
be noted, however, that two thirds of
vertebral fractures are asymptomatic.
Postmenopausal : dorsal kyphosis or gibbus
(Dowagers hump), loss of height,
protuberant abdomen, paravertebral muscle
spasm, thin skin.

Based on the patient,

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there is no symptom
 DIAGNOSIS
History taking: risk factors
Physical examination: Based on patients
condition:
anthropometry, gait, deformity,
Risk factor: age
and ect Physical
Supporting examination: examination:
Laboratory: complete blood for antalgic gait and
basic disease screening, 24 hour crepitus
urine calcium, kidney function, Supporting
liver function, TSH level examination:
Bone biochemistry 1. there is no
Radiology abnormality
2. Radiology:
Densitometry (Gold Standard)
Osteoporosis
DEXA scan: interpretation

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 Standard Laboratory Tests
CMP (creatinine, calcium, alkaline phosphatase)
Creatinine: assess for renal function for choice of treatment
Calcium:
if too low consider cause and replete
If too high consider hyperparathyroidism

Alkaline phosphatase: osteomalacia or Pagets disease

25-OH Vitamin D
Important to replete if low (low vit D can lead to elevated PTH)

24-hour Urine calcium

Hypercalciuria: if elevated
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Malabsorption: if low
Normal BMD BMD above > - 1 SD from No
the young normal mean
Low BMD or
osteopenia BMD - 1 SD and 2.5 SD Prevention

Osteoporosis BMD is reduced < 2.5 SD Treatment

Severe or established BMD is reduced < 2.5 SD Treatment

osteoporosis in the presence of fractures
NON PHARMACOLOGICAL
Adequate nutrition, particularly calcium and vit. D
Calcium: 1000 1200 mg daily (diet plus supplementation)
Vitamin D: goal level of around 30-50 (most 1000 units daily)
Weight bearing exercise
Discourage smoking
Discourage alcohol abuse
Reduction of risks for falling: consider OT evaluation for home hazards,
minimize sedating medications.
Hip protectors: can be useful if worn properly but often have low compliance.

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TREATMENT OPTIONS
Nutritional Recommendations
Calcium ( >51 and older = 1200mg/d)
Vitamin D supplementation for daily intakes (based on obtaining a
serum level of 20 ng/mL). 400-800 IU for those >70 years.
Other nutrients such as salt, high animal protein intakes, and
caffeine may have modest effects on calcium excretion or
absorption. Adequate vitamin K status is required for optimal
carboxylation of osteocalcin
 TREATMENT OPTIONS
Pharmacology Recommendation
Bisphosphonates
SERMs (Selective estrogen receptor modulators) raloxifene, tamoxifen, bazedoxifene:
used currently in postmenopausal women
Calcitonin : no longer used
Estrogen: oral estrogens (esterified estrogens : 0.3 mg/d, conjugated equine estrogens :
0.625 mg/d, ethinyl estradiol : 5 g/d) transdermal estrogen, 50 g estradiol per day,

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