OSTEOPOROSIS

IIN NENSI MENDO TANDIRERUNG.

SITI HARDIYANTI M.

INTERNAL MEDICINE DEPARTMENT -RHEUMATOLOGY

 PATIENT IDENTITY
• Name : Mrs. BS
• Age : 62 years old
• Address : Utan Lotong, Luwu
• Occuption : Farmer
• Religion : Moslem
• Hospital : Wahidin Sudirohusodo
• Room : Lontara 1, 5/II/3
• MR : 829487
• Date of Entry : March 8, 2018
HISTORY TAKING
 Chief Complain: Low back pain
 Patient comes with low back pain since 9 days ago.
Pain worsening when walking and decrease when
resting. Patient complain of weakness continuously.
Patient also complain pain in the right knee and
worsening by activity. No swelling, warm or reddness
of the right knee. But patient has history swelling and
pain 1 week ago. Defecation and urination was
normal. Patient with chronic kidney desease on
hemodialysis 3x/week.
HISTORY TAKING
 There is history of high uric acid and medication of
allopurinol since 3 years ago.
 There is history of pain in MTP 1
 History of hypertension since 8 years ago, with medication
of amlodipine and clonidin.
 There is no history of diagnosed as osteoporosis before
 History of herbal consumption (+)
 Family history of osteoporosis denied.
 PHYSICAL EXAMINATION

GENERAL DESCRIPTION VITAL SIGN

General condition : Mild illness Awareness : Conscious
Blood Pressure : 100/70 mmHg
Height : 150 cm
Heart Rate : 80 x/minute
Weight : 50 kg
Respiratory Rate : 20 x/minute
BMI : 22,22 kg/m2
Temperature : 37,0ᴼC
VAS : 6/10
PHYSICAL EXAMINATION
• Head : Normocephal, grey hair, not easy to remove
• Face : normal
• Eyes : Pupils isochor, conjunctiva anemic (+)
• Ear : No abnormalities, otorrhea (-)
• Nose : No abnormalities, secret (-)
• Oral cavity : oral trush (-)
• Throat : No abnormalities, pharyngeal hyperemia (-), T1-T1
• Neck : JVP R + 1 cmH2O, no lymphadenopathy, no deviation
of the trachea.
PHYSICAL EXAMINATION
• Lung
• Inspection : Symmetrical left and right
• Palpation : focal fremitus normal
• Percussion : Sonor
• Auscultation : Vesicular breathing sounds, wheezing (-), ronchi (-)
• Heart
• Inspection : Ictus cordis seen
• Palpation : Ictus cordis palpable at ICS V linea midclavicularis
• Percussion : Dull, left heart border ICS V linea midclavicularis
• Auscultation : heart sound I / II regular, no murmur
 PHYSICAL EXAMINATION
• Abdomen
• Inspection : flat
• Auscultation : Bowel peristalsis (+) normal
• Palpation : no pain on palpation, liver and spleen not palpable
• Percussion : timpani
RHEUMATOLOGICAL STATUS
• Gait : unable to walk

• Arm : normal

• Leg : tenderness (-), dolor (+), rubor (-), kalor (-), limited
ROM (-), crepitation (+) on both of genu,genu Lebih hangat yang
sebelah kanan

• Spine : tenderness (-), dolor (+), rubor (-), kalor (-), mass (-),
alignment within normal limit
PATIENT PROFILE
PATIENT PROFILE
PATIENT PROFILE
 ECG
ECG

Sinus rhythm, HR 75 x/mnt, regular, normoaxis

 LABORATORY FINDINGS
Blood Routine (3/8/2018)
Leukosit 15.200 4000-11.000/µL
Eritrosit 2.4 x 106 4.5-6.5 x 106 / µL
Hemoglobin 6.6 13.0 – 16.0 g/dL
Hematokrit 21% 40-54%
Trombosit 230.000 150.000-400.000 / µL
MCV 87.5 80-97
MCH 27.5 26,5-33,5
MCHC 31.4 31,5-35
Neutrophyl 89.7% 50-70%
Limphocyte 7% 20-40%
Moncyte 3.2% 2-8%
 LABORATORY FINDINGS
(3/6/2018)
PT 10.6 10-14 s
APTT 27.2 22-30 s
GDS 81 140 mg/dl
Ureum 26 10-50 mg/dl
Creatinin 2.99 M(<1.3), F(<1.1)
Albumin 2.4 3.5-5.0 gr/dl
Uric acid 3.1 M(3.4-7.0), F(2.4-5.7)
Natrium 137 136-145 mmol/l
Kalium 3.3 3.5-5.1 mmol/l
Clorida 103 97-111 mmol/l
 LABORATORY FINDINGS
Urinalysis (7/3/2018)
Color Yellow Clear yellow
pH 6.0 4.5-8.0
Pro +3 Negative
Glu Negative Negative
Bil +1 Negative
Nit Positive Negative
BLD Negative Negative
Leu +1 negative
 GENU X-RAY

IMPRESSION :
OSTEOATHRITIS GENU DEXTRA GRADE 1
OSTEOPROSIS SENILIS
LUMBALSACRAL X-RAY IMAGING

IMPRESSION :
SPONDYLOSIS LUMBALIS
OSTEOPOROSIS SENILIS
ABDOMINAL USG
• PNC Bilateral (1/9/2018)
 ASSESMENT
 Osteoporosis
 LBP ec spondylosis lumbal
 Secondary knee OA
 Interkritikal Gout Arthritis
 PNC G5D
 PROBLEM LIST
Assessment Planning Planning Therapy
Diagnostic
1 Osteoporosis Bone Mineral Cavit D3 1 tablet/8jam/oral
Based on : Densitometry (BMD)
 Woman 62 years old
 Post menopause
 She has 5 childrens, with 2
months breastfeeding each.
 X-Ray imaging of lumbal:
osteoporosis senilis
 X-Ray imaging of genu: decrease
of bone mineralization
 PROBLEM LIST
Assessment Planning Planning Therapy
Diagnostic

2. LBP ec. Spondylosis lumbal - - Medical rehabilitation

Based on :
- Low back pain since 9 days ago
- X-ray imaging of lumbal:
spondylosis lumbalis
 PROBLEM LIST
PROBLEM LIST
Assessment Planning Diagnostic Planning Therapy

3. OA Genu dextra X-ray genu bilateral • meloxicam 15 mg/24

Based on : hours/oral
 Crepitation (+) • Omeprazole 40 mg/12

 62 years old hours/iv

 Dolor (+)
 No warm
4/6 sign
 PROBLEM LIST
Assessment Planning Planning Therapy
Diagnostic

4. Gout Arthritis interkritikal Uric acid - Allopurinol

Based on : X-ray 100mg/48hours/oral
• There is history of high uric acid
and medication of allopurinol
since 3 years ago.
• Patient is not pain or swollen
now
 PROBLEM LIST
Assessment Planning Planning Therapy
Diagnostic

5. PNC G5D - According to Renal and

Based on : hypertension division:
• Hemodialysis since 2 months
ago
• Ureum (26 mg/dl):Cr(2.99)
• Usg abdomen: PNC bilateral
DISCUSSION
OSTEOPOROSIS
WHAT IS OSTEOPOROSIS ?
Osteoporosis is defined as a reduction in the strength of bone
that leads to an increased risk of fractures.

The World Health Organization (WHO) operationally defines

osteoporosis as a bone density that falls 2.5 standard
deviations (SD) below the mean for young healthy adults of
the same sex
 PATOPHYSIOLOGY
Menopause

↓ estrogen

Bone marrow Endothelial

Osteoblast Osteoclast ↓ intestinal
Stromal cell + cell ↓kidney calcium
calcium
mononuclear absorbtion
absorbtion
cell

↑IL-1, TNF-α, IL-

↓ TGF-β ↓ NO
6, M-CSF Hipocalsemia

↑osteoclast ↑PTH
maturation
↑bone resorption

Osteoporosis Buku Ajar Ilmu Penyakit Dalam. 6th ed. 2014

 CLASSIFICATION
Primary osteoporosis : Secondary osteoporosis :
• Involutional • Drugs
Osteoporosis Type 1
• Life changes
(post menopausal)
• Other diseases
• Involusional
Osteoporosis Type 2
• (senile osteoporosis)
 DIAGNOSIS
 History taking & physical examination :
Osteoporosis is a silent disease until the patient
experiences a fracture, no spesific symptoms, no
pain.
 Laboratory findings : needed to rule out other
responsible diseases.
 Xray findings : decrease of bone mass density
 Gold standart: Bone Densitometry
 BONE DENSITOMETRY

Bone densitometry is a tool for measuring bone dencity. Bone densitometry also called dual
energy x-ray absorptiometry (DEXA). DEXA is most often performed on the lower spine and
hips.
INTERPRETATION BMD:
TREATMENT & PREVENTION
THANK YOU