Assessment

HISTORY. Take a careful history of all traumatic injuries, with a particular focus on previous bone fractures. Collect data about risk factors: age, sex, race, body frame, age of menopause onset, diet, patterns of alcohol intake, caffeine use, smoking, medications, concurrent medical conditions, and exercise habits. Inquire about complaints of back pain while lifting or bending, particularly when assessing elderly women. If the patient has vertebral collapse, she or he may describe backache or pain that radiates around the lower trunk and is aggravated by movement.

PHYSICAL EXAMINATION. Diagnosis of osteoporosis is typically made after the patient sustains a vertebral, wrist, or hip fracture. Often, the patient is asymptomatic before admission

674 Osteoporosis with a bone fracture. A typical first sign of osteoporosis is vertebral collapse on bending over; sudden lower back pain that radiates around the trunk is a common symptom.

Inspection of the vertebral column reveals curvature of the dorsal spine, the classic "dowager's hump." Often, the patients report a height reduction of 2 to 3 inches over 20 years. Palpation of the vertebrae that is accompanied by back pain and voluntary restriction of spinal movement are indicative of a compression vertebral fracture, which is the most common type of osteoporotic fracture. The most common area for fracture occurrence is between T-8 and L-3. The radius (Colles's fracture), hip, and femur are also gently palpated and assessed for pain and fracture.

PSYCHOSOCIAL. Assess the patient's concept of body image and self-esteem if there is severe curvature of the spine. Inquire about the patient's ability to find clothing to fit, any decrease in social activity, or alterations in sexuality. Evaluate the patient's home environment; inquire about fall risks in the environment—for example, stairs, waxed floors, and scatter rugs.

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Bone mineral density (BMD)

Within 1 standard deviation (SD) of young adult value (±1)

Reported as a T-score: Osteopenia: T-score of -1 to -2.5 SD

Osteoporosis: T-score of <-2.5 SD

Best predictor of fracture risk

Dual energy x-ray absorptiometry

Bone x-rays

No bone loss No bone loss

Severe osteoporosis: T-score of <-2.5 SD with fragility fracture(s)

Bone loss; cannot determine bone loss until 25%-40% has occurred

Measures bone mineral content at several sites

Determines structure of bone

Other Tests: Complete blood count, chemistry screening, thyroid-stimulating hormone level, urinalysis, serum protein electrophoresis, serum and urine calcium levels, vitamin D level, serum phosphorus levels, alkaline phosphatase, computed tomography (CT) scan

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