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Osteoporosis: Clinical Presentation and Diagnosis

by Carlo Raj, MD
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    00:02 Clinical presentation: Most patients may be in some... asymptomatic until there is a massive fracture of either the vertebrae or maybe perhaps the hip that I had mentioned earlier.

    00:13 There are greater than one inch loss of height; kyphosis because of issues within the vertebrae and with that kyphosis may then cause restriction of your thoracic cavity, thoracic cage.

    00:28 So, therefore, breathing becomes difficult; may result in even restrictive lung disease because of literally physical, mechanical restriction of your lung.

    00:39 Focused exam looking for signs of secondary causes, always is in endocrinopathy; is your patient corticoid, so on and so forth.

    00:47 Imaging: plain film, not sensitive for detecting early disease... not early on, your bone may actually still look rather normal.

    00:59 Lateral films used for-for visualizing spine compression fractures.

    01:03 Remember osteopenia, would mean decreased or thinning out of your trabeculae.

    01:10 There?s something called dual-energy X-ray absorp-absorptiometry known as the DXA scan.

    01:17 So, DXA scan, calculated bone mineralized density; bottom-line, that?s what a DXA scan will do.

    01:25 It will find out as to how dense your bone is.

    01:27 So, therefore, once, let?s say a female, has hit menopause, you can expect the DXA scan to show you decreased bone density.

    01:36 Measures bone-bone density; mineralization at the spine and your hip, two major sites that you worried about major fractures in a patient with osteoporosis.

    01:51 Low bone mineralization density correlates with increased risk of fracture.

    01:56 Results express in the following two scores: we have a T-score.

    02:01 You want to be at least familiar with what these mean and when you would even use this or apply this.

    02:06 A T-score will be used in a patient who you suspect an osteoporosis with your bone mineralization density, expressed in number of standard deviation above or below the mean of normal 30-year old patient.

    02:20 Then you have the Z-score, expressed relative to adults of the same age and gender as the patient.

    02:27 So, more or less you?re comparing this individual with the rest of the population; T, Z-score being expressed for proper bone mineralization density.

    02:40 The scan that you will be using here is called a DXA scan, a dual-energy X-ray absorptiometry.

    02:46 WHO criteria for osteoporosis include the following.

    02:51 It?s important that you pay attention to the T-score.

    02:55 Remember that the T-score is then going to measure as to what your bone mineralization density would be.

    03:01 If it?s greater than -1 and then it will be normal; if it?s -1 to -2.5, you start getting into trabeculae thinning out.

    03:10 This is referred to as being your osteopenia.

    03:13 If it?s less than -2.5, osteoporosis increased porosity and if it gets much less than -2.5, this is important because now you are increased in risk of fractures in two major places - the hip and the spine.

    03:32 Indications for DXA scan: postmenopausal.

    03:34 Remember, what is DXA scan measuring for? Bone mineralization density.

    03:40 Therefore, in a postmenopausal woman, above the age of 50; here we are above 65, for sure.

    03:48 Postmenopausal less than 65 years with clinical risk factors, definitely.

    03:52 So, now, there?s a family history of osteoporosis in this female and she?s at menopause, clinical risk factors, DXA.

    04:01 Aid in decision regarding hormone replacement therapy, if required and by hormone, of course, we are replacing our estrogen.

    04:08 Radiologic evidence of osteopenia, meaning to say that you find your trabeculae to be thinned out and there?s prior osteoporotic fractures.

    04:17 All these would be indications and your monitoring therapy for osteoporosis.

    04:24 The biochemical assessment osteoporosis, what are you looking for? Upon CBC, you are looking for calcium, looking for phosphorus and alk-phos or alkaline phosphatase.

    04:34 In other words, aren?t these electrolytes and such and enzymes that you?re looking for when you are referring to proper bone homeostasis? Screen, hyperthyroidism could be an issue.

    04:47 So, screen for TSH.

    04:49 Also, screen for 25.

    04:51 Why not 125? Because the major Vitamin D that?s circulating in our bodies right now is the 25-type that was hydroxylated by the liver.

    05:02 Other tests sent based on history, physical, initial lab; we have something called SPEP and UPEP, 24-urine calcium, intact PTH and testosterone, especially in men.

    05:13 These are things that you want to keep in mind as you get into further differentials.


    About the Lecture

    The lecture Osteoporosis: Clinical Presentation and Diagnosis by Carlo Raj, MD is from the course Bone Disease.


    Included Quiz Questions

    1. Restrictive lung disease
    2. Hip fracture
    3. Hypercalcemia
    4. Vertebral compression fracture
    5. Endocrine abnormalities
    1. Scan completed at 2 sites- the spine and the knee
    2. Calculates bone density
    3. Expressed as 2 scores
    4. Uses photon beams of 2 different energy levels
    5. Involves comparison to an average mean of a 30 year old patient
    1. Osteopenia
    2. Normal BMD
    3. Osteoporosis
    4. Severe osteoporosis
    5. Severe osteopenia
    1. A patient that has been diagnosed with osteopenia
    2. 63 year old woman in good health
    3. 60 year old man with clinical risk factors
    4. A patient who is on hormone replacement therapy
    5. A patient with no history of osteoporotic fracture

    Author of lecture Osteoporosis: Clinical Presentation and Diagnosis

     Carlo Raj, MD

    Carlo Raj, MD


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