Osteoporosis: Clinical Presentation and Diagnosis

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 is 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 is 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? A good place to start would be a CBC and chemistry panel The chemistry panel normally includes calcium, phosphorous and alkaline phosphatase.

04:35 In other words, are not these electrolytes and such and enzymes that you are looking for when you are referring to proper bone homeostasis? Screen, hyperthyroidism could be an issue.

04:49 So, screen for TSH.

04:50 Also, screen for 25.

04:52 Why not 125? Because the major Vitamin D that is 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.