OSTEOPOROSIS

VERRY ASWARD SAMIUN C014172178

LUTHFI THUFAIL AKMAD C014181
A.DWIKI CAHYADI YUSUF C014181

DEPARTMENT OF INTERNAL MEDICINE

RHEUMATOLOGY DIVISION
2019
 PATIENT IDENTITY
Name : Mrs. Hj. S
Age : 72 yo
Address : Makassar
Religion : Islam
Status marital : Married
Room : PJT
Medical Record : 644482
 HISTORY TAKING
Consult from cardiologist with Low Back Pain
Chief complaint:
History of low back pain was felt since 1 month ago, pressure
sensation, felt continously, before pain didn’t fell better with rest and
taking medicine, worsening when doing activity such as walking and
sitting. There isn’t stiffness in the joint especially in the morning.
History of trauma (-). But since yesterday, she felt no pain. She was
consumed paracetamol 1000mg, calcium 500mg, methylcobalt 500mcg
and cavit D3 routinely.
 HISTORY TAKING
 Fever (-), headache (-), cough (-), shortness of breath (-), DOE (+).
 No Cough, There was shortness of breath in the last 1 years ago
intermittenly, shortess of breath worsened when doing activity.
 No abdominal pain, no vomiting.
 Defacation : normal
 Mixturation : normal
 There is history of valvular disease since 4 years ago, patient
routinely consumed simarc 2 mg 1x1, digoksin 0,25 mg 1x1, ISDN
5mg.
 HISTORY TAKING
 History of occupation: Patient is housewife, she rarely do physical
activity in the outside.
 History of menopause since 25 years ago.
 History of gravid: Patient has 4 daughters.
 History of trauma: Patient had have deformity in the left wrist joint
because of trauma.
 No history of reumatic disease.
 PHYSICAL EXAMINATION
General Description
Impression : moderate illness
Nutritional status : normoweight
Consciousness : composmentis
Vital Signs
Blood pressure : 99/50 mmHg
Pulse : 44 beats / min, regular
Respiration : 18 times / min
Axillary temperature : 36,8° C
VAS : 1/10
 PHYSICAL EXAMINATION
Head and Neck:
Pale Conjunctiva (-), Icteric (-), Cyanosis (-)
No lymph enlargement and stiff at neck

Thorax :
I : Symmetrical left and right,
P : No tumor mass, no tenderness
P : Sonor in both lung fields
A : ronchi (-/-) basal bilateral, wheezing (-/-)
 PHYSICAL EXAMINATION
Heart :
I : Ictus cordis unseen
P : Ictus cordis palpable at ICS V linea medioclavicularis sinistra
P : Right heart border in ICS IV linea parasternalis dextra;
Left heart border in ICS VI linea medioclavicularis sinistra
A : Heart sound I / II pure, regular. Systolic murmur 3/6 apex
Abdomen :
I : Follow the motion of breath
A : Peristaltic (+) normal impression
P : Liver and spleen are not palpable
P : Tympani (+)
 RHEUMATOLOGY STATUS
G (Gait) : able to walk
A (Arms) : deformity of wrist joint sinistra (+), Pain (-)
tenderness (-), Kalor (-), Dolor (-)
L (Legs) : pain (-) tenderness (-) kalor (-) dolor (-) rubor (-)
limited ROM (-), strength 5, patologic refleks (-)
S (spine) : tenderness (-),
laseque test (-)
scoliosis (-), Kifosis (-), Lordosis (-)
PATIENT PROFILE
ECG

Conclusion: Supraventricular Rhythm, HR: 56 times/minute, normoaxis.

 LABORATORY FINDING (11-03-
2019)
Laboratory Findings Normal Range
WBC 5900 /uL 4.00 – 11.00
HGB 15.4 g/dL 13.0 – 16.0
PLT 204 x 10^3 /uL 150 - 450
Neut 57.5 % 50.0 –70.0
Ureum 67 mg/dl 10-50
creatinin 0.87 mg/dl <1.1
SGOT 75 U/L < 38
SGPT 40 U/L < 41
 LABORATORY FINDING (11-03-
2019)
Laboratory Findings Normal Range

GDS 131 mg/dl 144

Natrium 137 mmol/l 135 – 145
Kalium 3.2 mmol/l 3.5 - 4.5
Clorida 97 mmol/l 95 - 105
Lumbosacral
X-Ray (2-2-19)
• Spondylosis lumbalis
• Stenosis discus
intervertebralis CV
L1-L2
 ASSESMENT
ASSESMENT

 Low Back Pain ec Spondylolistesis Lumbalis

 Senile Osteoporosis

 CHF NYHA II

 Atrial Fibrilasi Slow Ventricular Response

 PROBLEM LIST
Problem
1. Low back pain ec
spondylolistesis lumbalis
Based on:
• low back pain , felt
continuously, no spread since
1 month ago
• Lumbasacral photo rontgen:
Spondylosis lumbalisVL4-5
Plan Diagnostic Plan Therapy
MRI lumbosacral Paracetamol 1000mg/12hr/oral
Education plan:
Explaining about the
disease, examination plan,
management, complications,
and prognosis of the disease
Physiotherapy
 Problem Plan Diagnostic Plan Therapy
2. Senilis Osteoporosis BMD Calcium 500mg/24jam/oral

Problem
Based on:
List Cavit D3 tab/24jam/oral
Zolendronat Acid infuse/
• Low back pain, age of patient
intravenous/years (runs out in
> 50 yo, female. Patient is
housewife and rarely do 1 hour)
physical activity in the outside.
Education plan:
• History of menopause since
Explaining about the disease,
25 years ago
examination plan,
• Radiology findings: management, complications,
Osteoporosis and prognosis of the disease
 Problem Plan Diagnostic Plan Therapy
3. CHF NYHA II Echocardiography According to Cardiologist:

Problem List
Based on:
• Short of breathness since 1
Furosemid 40 mg/24 hr/oral

years. DOE (+)

• Thorax photo rontgen:
cardiomegali with dilatation
aortae

4. Atrial Fibrilation Slow

Ventricular Response
Based on:
• PE: HeartRate:45times/minute
• ECG: Supraventrikuler rhythm,
HR: 56 times/minute,
normoaxis.
DISCUSSION
 DEFINITION
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

Kasper D et al, 2015. (Harrison’s Principle of Internal Medicine, 19th ed.)

 EPIDEMIOLOGY
 Bone loss as a result of aging and/or estrogen deficiency is the
predominant pathophysiologic disorder of primary osteoporosis.
 In the United States, as many as 9 million adults have
osteoporosis (T-score <–2.5 in either spine or hip), and an
additional 48 million individuals have bone mass levels that put
them at increased risk of developing osteoporosis (e.g., bone
mass T-score <–1.0).

Kasper D et al, 2015. (Harrison’s Principle of Internal Medicine, 19th ed.)

 EPIDEMIOLOGY
 The Indonesian population is expected to grow by 20% over the
next four decades, from 251 million in 2013 to 300 millions in
2050.
 Life expectancy is likely to reach age 80 years by 2050, and 11%
increase from current 72 years
EPIDEMIOLOGY
 One of few studies on BMD levels and
osteoporosis prevalence (T score <-2.5) in
the Indonesian population was conducted
in 2006.
 Results found that the prevalence of
osteoporosis in women aged between 50-
80 years was 23% and between 70-80
years was 53%.
 In men, BMD decreases of 10-20%
between the ages of 20-39 years and 70-
79 years were shown.
RISK FACTOR
 CLASSIFICATION
CLASSIFICATION
Primary Osteoporosis Secondary Osteoporosis
 Involutional  Drugs
Osteoporosis Type 1  Life changes
(post menopausal)  Other diseases
 Involusional
Osteoporosis Type 2
(senile osteoporosis)

Sözen T, Özışık L, Başaran NÇ. An overview and management of

osteoporosis. European Journal of Rheumatology. 2017
 Osteoporosis Involutional
Characteristics
Type I (Post Menopause) Type II (Senile)
Age 50-75 >70
Sex Ratio (F:M) 6:1 2:1
Type of bone loss Mainly trabecular Cortical and trabecular
Bone turnover Accelerated Not accelerated
Fracture types Vertebral, distal radius Vertebral, neck femur
Parathyroid function Decreased Increased
Main causes Estrogen deficiency Aging, calcium deficiency
 PATHOPHYSIOLOGY
Menopause

↓ estrogen

Bone marrow Endothelia

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

↑IL-1, TNF-α,
↓ TGF-β ↓ NO Hipocalsemia
IL-6, M-CSF

↑osteoclast
maturation ↑bone ↑PTH
resorption

Osteoporosis

Buku Ajar Ilmu Penyakit Dalam. 6th ed. 2014

 PATHOPHYSIOLOGY
Aging
Vitamin D deficiency, ↓ Calcium absorbtion
↓ 1-a hidroksilase activity in intestine

↓ Calcium reabsorption
in renal

↓ GH & IGF-1 ↓ physical ↓ estrogen

secretion activity secretion
Secondary
hyperparathyroidism
Osteoblast function
Bone turnover
disturbance

Osteoporosis

Buku Ajar Ilmu Penyakit Dalam. 6th ed. 2014

 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
DIAGNOSIS
TREATMENT & PREVENTION
THANK YOU