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Muh.

Ismail Pratama
A. Tenri Luwu
Mutmainnah

Presented as a Clinical Clerkship Assignment


Department of Internal Medicine, Faculty of Medicine, Hasanuddin University
November 2017
 Name : Mrs. M
 Age : 32 years old
 Enter hospital : 17-10-2017
 Occupation : Staff Administration
 Religion : Moslem
 Ethnic : Makassar
 Marital Status : Married
 Chief complaint : Low back pain
Patient admitted to the hospital with chief complaints of low
back pain already experienced 1 month ago, but become worst
in 1 week. Low back pain is increased when the patient moving,
and reduced when laying in supine position. The pain is radiated.
There is history of trauma (fall in sit position) 1 month ago. No
history of lifting heavy weight. Patient is difficult to walk due to
pain.
There is history of asthma since childhood and got prednisone
since that. There is no history of acute pain or swelling joints. No
pain and stiffness on patient’s knee. There is no history of
hyperuricemia.
- No fever and cough
- Decrease of appetite since few weeks, no nausea and vomiting
- Defecation: normal
- Urination: normal, yellow color.
- No history of DM and hypertension
- History of first menstruation at 16 years old
- History of Asthma since childhood
- History of long-term corticosteroid intake.
- No history of smoking and alcohol consumption
General Description
General condition : Moderate illness
Nutritional status : 21,4 kg/m2 (normal)

 Vital Signs
 Consciousness : Compos mentis (GCS 15 E4M6V5)
 Blood pressure : 100/70 mmHg
 Heart rate : 88 x/ min regular
 Respiratory rate : 20 x/min
 Temperature : 36,9°C (axilla)
 NRS : 7/10
 Head : Normocephal
 Face : Normal
 Eyes : Isocor pupils, normal light reflex, no icteric sclera, 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
 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
 Gait : Unable to walk
 Arm : normal
 Leg :
Both thighs look small compared with top body parts
Genu (D) et (S) : kalor (-), dolor (-), rubor (-), crepitation(-),
effusion (-), limited ROM (-)
 Spine : Laseque (+)
 Ur/ Cr : 39/1,07
WBC : 6300  Chol : 206

HGB : 14,2  Tg/HDL/LDL :127/38/147


 Alb./Glob . : 3,9/2,9
PLT : 344
 FPG : 277
AST : 11  Urinalysis:
 Protein, erythrocytes,
ALT : 14 leukocytes (-)
 Glucose (+)
Thoraks X-ray
 Compression fractured
of CV L1, L4, L5
 Osteoporosis
DXA examination results:
 L2-L3: -3.8 SD
 L2- L4: -3.8 SD
 L3-L4: -3.8 SD
 Neck of femur : -3.4 SD
 Conclusion:
Osteoporosis
Assessment Planning Diagnostic Planning Therapy
1. LBP ec Compression Fractured MRI lumbosacral - Meloxicam 15 mg/
vertebrae
Based on : 24hrs/oral
- Great low back pain
- Progression from pain to
difficult to walk in 7 days
- osteoporosis as risk factors
(female,history of long term
corticosteroid intake)
- Laseque (+)
- lumbosacral radiology
• Compression fractured of CV L1,
L4, L5
Assessment Planning Diagnostic Planning Therapy
2. Corticosteroid induce Osteoporosis • High Calcium Diet
Based on: • Actonel 1x5 mg/hari
• Women • Osteocal 2x500 mg
• History of long term corticosteroid • Arnid 2x1 tablet/hari
intake • Inflamed 2 x puff I
• Lumbosacral radiology : signs of
osteoporosis+fracture
• Bone mass densitometry :
Osteoporosis

3. Corticosteroid induce Dibetes OGTT • Diet DM 1700 kkal


Mellitus • Mixtard novolet 10-0-8 IU
Based on :
• History of long term corticosteroid
intake
DISCUSSION
 Osteoporosis is a metabolic bone disease
characterized 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
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.
Source: Canalis, et.al. Osteoporosis Int 2007 in dr. Faridin’s Slide
 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

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 Patients who have sustained a vertebral
compression fracture may note progressive
kyphosis with loss of height. They may also
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
(Dowager’s hump), loss of height, protuberant
abdomen, paravertebral muscle spasm, thin
skin.
History taking: risk factors
Physical examination: anthropometry, gait, deformity,
and ect
Supporting examination:
Laboratory: complete blood for basic disease
screening, 24 hour urine calcium, kidney function,
liver function, TSH level
Bone biochemistry
Radiology
Densitometry (Gold Standard)
Radiology

Not a sensitive modality, as more than 30-50%


bone loss is required to appreciate decreased bone density on radiograph
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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
 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
 Hip protectors: can be useful if worn properly but often have low
compliance.

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 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
PHARMACOLOGY RECOMMENDATION

 Bisphosphonates : Alendronate, risedronate, ibandronat, and zoledronic acid


are approved for the prevention and treatment of post-menopausal
osteoporosis. Alendronate, risedronate and zoledronic acid are also approved
for the treatment of steroid induced osteoporosis.

 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 μg/d) transdermal estrogen, 50
μg estradiol per day,

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THANK YOU