NYU Medical Grand Rounds Clinical Vignette Deepa Rani Nandiwada, M.D. PGY 2 November 1, 2011 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

NYU Medical Grand Rounds Clinical

Vignette

Deepa Rani Nandiwada, M.D. PGY 2November 1, 2011

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

• 74 year old female, presenting with repeat hip fracture one week ago, while on teriparatide for treatment of her osteoporosis.

Chief Complaint


• Patient was diagnosed with osteoporosis 10 years ago, and has been on treatment with alendronate, until recently (She self discontinued due to fear of side effects). •She is still taking calcium and Vitamin D supplementation.

History of Present Illness


•She was diagnosed with ductal carcinoma in situ (estrogen receptor postive) breast cancer in 2007 and subsequently underwent lumpectomy, radiation, and anastrazole therapy.

•In June of 2009 she broke her hip while on bisphosphonates.

•T scores on repeat dexa continued to be < -3.5 at multiple sites



•She was then started on teriparatide and her anastrazole was switched to tamoxifen in April of 2011

•Patient is now presenting to clinic with repeat contralateral hip fracture while being on long term bisphosphonates, teriparatide, anstrazole then tamoxifen, calcium, and vitamin D supplementation.



Additional History

•Past Medical History:• Hip Fracture in 2009•Multiple compression fractures• Hypothyroidism• Ductal carcinoma in situ - estrogen and progesterone receptor positive, her-2 neu negative

•Past Surgical History:• Left sided lumpectomy 2007

•Social History:• Denies tobacco, alcohol, drug use• Lives in Brooklyn with a caretaker, and now requires a walker after the hip fracture


Additional History

•Family History:•Non contributory

•Allergies: •No Known Drug Allergies

•Medications:• Tamoxifen 20mg daily• Teriparatide 20mg SC daily•Valsartan 80mg daily• Levothyroxine 88mcg daily.


Physical Examination

• Vital Signs: list T:98.5 BP: 139/90 HR: 88 RR: 12 and O2 sat: 98% BMI: 29• General: thin, frail appearing, kyphotic elderly woman in no acute distress.•Musculoskeletal: significant kyphosis, no scoliosis or lordosis•Remainder of physical exam was within normal limits


Laboratory Findings

•Calcium: 9.6 (normal range 8 – 10.4)•PTH: 19 pg/ml (normal range 10 -60 pg/ml)

•Remainder of labs were also within normal limits


Other Studies

•Dexa T score of -3.5 at spine ( T score of -1.5 standard deviations defines osteopenia. T score – 2.5 standard deviations defines osteoporosis).


• Osteoporosis with treatment failure in need of further evaluation for secondary causes including:

• Hypoparathyroidism• Multiple myeloma• Hypothyroidism• Malignancy

Differential Diagnosis


• Osteoporosis with treatment failure now awaiting work up for secondary causes of osteoporosis.

Final Diagnosis


Documents

NYU Medical Grand Rounds Clinical Vignette Deepa Rani Nandiwada, M.D. PGY 2 November 1, 2011 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS