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INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please explain the test results to Flora and develop a management plan with her for the prevention of further osteoporotic fractures.

Scenario

In January of this year Flora McMillan, aged 73, fell on her left arm and sustained a Colles fracture. She recently had a bone densitometry scan done and the results are:

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Scan BMD g/cm2 T-score Fracture risk Z-score Peer relationship
Lumbar spine 0.854 −2.6 Marked −1.2 Lowest quartile
Total femur (L) 0.686 −2.6 Marked −1.5 Lowest quartile

T-score—comparison with young normal adult

Z-score—comparison with aged matched controls

The following information is on her medical record:

  • Past medical history

  • Hyperlipidaemia

  • Medication

  • Simvastatin 40 mg od

  • Allergies

  • Nil known

  • Immunisations

  • Up-to-date

  • Family history

  • Father died of a myocardial infarction, aged 45

  • Social history

  • Teacher, semi-retired

  • Non-smoker

  • Height 1.6 m

  • Weight 53 kg

  • BMI 20.7 kg/m2.

INSTRUCTIONS FOR THE PATIENT, FLORA MCMILLAN

You are a 73-year-old teacher. You work part-time in the school library. In January of this year, you tripped over while on a walking holiday and broke your left wrist. (You did not quite hear the name of the fracture—it sounded like a Collie fracture but you though Collies were dogs.)

You are now back at work. Your wrist is apparently healed but it feels stiff in the morning and aches after a long day of carrying books.

Your GP arranged a bone density scan. You are here to find out the results and want to hear about anything you can do to prevent further fractures.

The following information is on your medical records:

  • Past medical history

  • Hyperlipidaemia

  • Medication

  • Simvastatin 40 mg od

  • Allergies

  • Nil known

  • Immunisations

  • Up-to-date

  • Family history

  • Father died of a myocardial infarction, aged 45

  • Social history

  • Teacher, semi-retired

  • Non-smoker

  • Height 1.6 m

  • Weight 53 kg

  • BMI 20.7 kg/m2.

SUGGESTED APPROACH TO THE CASE

Establish rapport

Check reason for attendance—to obtain results of bone density scan

Give results

  • — Explain results in terms that Flora understands—scan demonstrates osteoporosis (‘thinning of the bones’)

  • — Link osteoporosis with recent fracture

  • — Explain risk of further fractures and need to prevent

Maintain/improve bone density

  • — Calcium intake—recommended 1000–1500 mg calcium per day, ideally through low-fat dietary sources; may need supplement if unable to meet requirements in diet

  • — Vitamin D—assess sun exposure, check and replace Vitamin D if at risk

  • — Weight-bearing exercise 30–60 minutes, three to four days per week

  • — Initiate treatment with anti-osteoporosis medication, e.g. bisphosphonate or denosumab

  • — Avoid excess alcohol and caffeine. Don’t start smoking

Fracture ...

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