Wednesday, May 25, 2011

Brittle Bones

I walked into the clinic exam room to find a new patient sitting quietly on the table.  I introduced myself and asked her why she had come in.
“My husband and I just retired and moved down here from Chicago.  So I’m in need of setting up medical care.  I have high blood pressure and need my medication refilled.”
“Okay, well then let’s start with what blood pressure medication you’re on.”
“I take lisinopril 5 mgs and hctz 25 mgs a day.”
“Sounds to me like you’re on a relatively low dose of blood pressure meds.  What do your blood pressure readings at home generally read?”
“I’m supposed to be taking my blood pressures at home?”
“Yes, you should be taking your blood pressures at home with a reliable machine.  I like to recommend you pick up an omron blood pressure machine, they can be bought at most drugs stores.  Don’t buy the one that measures your blood pressure at the wrist, but buy the one that measures your readings on your arm, just above your elbow.”
“I see.  Well it looks like I’ll need to drop by the drug store on the way home.”

High blood pressure (medical term: hypertension) is a very common chronic medical condition found in patients being treated by their primary care physicians.  It can lead to a patient having a stroke, heart attack, blood vessel disease (aneurysms), kidney disease, and eye disease (retina).  Due to it not typically causing symptoms it is called the ‘silent killer.’ 
Too many patients don’t stay on their blood pressure medications, or they have side effects to them and stop them without letting their physicians know.  Another part of the puzzle is that patients don’t understand why they need to take a daily medication for their blood pressure when they are not having symptoms.     
Patients also need to be taught to take control of their hypertension by taking their blood pressures at home with a reliable machine.  They need to be informed that their at home readings (if normal) are showing them that the medications they take for their blood pressure are working and to not stop them. 

“Well, your blood pressure here this morning was 132/80, which is okay.  Your blood pressure readings should be below 140/90, preferable they should be below 130/80.  Why don’t you go buy a good blood pressure machine, like you said, start writing down your readings that you acquire and bring them back into me in 2-3 weeks so that I can see them.  It would be preferable if you took a reading in he am, just as you wake up and before you get out of bed, then again midday, and again just as you go to bed.”
“Okay, well it sounds as though I can do that.”
“Alright, well then why don’t you tell me what other meds you are on, and what medication allergies you have.”
“I take some calcium for my bones and it has Vitamin D in it.  I don’t have any allergies.”
“Do you have any other medical problems besides your high blood pressure?
“No, I just have some occasional seasonal allergy problems, which I take some Zyrtec for when I start having a drippy nose.”
“Okay, well how about any prior surgeries?”
“I had two C Sections, and my gallbladder removed.”
“And what about your family history, do you have any history of cancer, heart disease, osteoporosis, for example?”
“My father died of a heart attack and my mother died of a stroke.  My sister died of breast cancer, and my two brothers are both on blood pressure medicines. 

After I did my physical exam, Dorothy and I settled on her returning to the clinic to be seen with her home blood pressure readings in 2-3 weeks.  I gave her a lab slip to have some preliminary blood work done, which would check her kidney function and electrolytes.
Three weeks later I walked into the clinic exam room to see Dorothy again. 
“Morning, Dorothy, how are you?”
“I’m fine.  My husband and I are settling into our new home and I think we’re going to enjoy living down here.”
“Well I hope so, it’s generally thought of as a nice place to retire.”
“Here’s what you requested, I have a list of my blood pressure readings for you.”
Dorothy handed me the sheet of information, which I reviewed with her.  I was happy to see that her blood pressure readings at home were good with an average of all of her readings being 115/74. 
“I’m glad to see these readings, Dorothy.  The medicine you’re on is working well for you, so we’ll keep you on it.  Your lab work from a few weeks ago was normal.”
“Glad to hear it.”
“Okay, now the other medicine you’re on is calcium with Vitamin D.  When was the last time you’ve had a bone scan done to look at your bone density?”
“I don’t think I’ve ever had one of those done.  I’ve been more concerned about making sure to get my mammograms done every year due to my sister’s breast cancer history.”
“Well that’s understandable.  When was the last time you had a mammogram?”
“Three months ago, it was normal.

Patients who have a family history for cancer need to be screened differently than the general population.  For those who have breast cancer in their family they need to be diligently screened with a mammogram and advised to be seen by their medical provider if they notice any changes in their breast, such as a new nodule, dimpling of the skin, drainage from their nipple).  If the patient has a family history of colon cancer they need to begin screening with a colonoscopy (done by a gastroenterologist) 10 years prior to the first episode of colon cancer in their relative (i.e. relative with colon cancer at age 50, the patient needs to begin screening at age 40). 

“Okay, well then let’s get you scheduled for a bone scan to assess your bone density.  Why don’t I see you in about 3 months as a follow-up after your bone density is done and you can bring in another list of your blood pressure readings at home at that time.”
“Okay, sounds good to me.”
As Dorothy got up to leave, I gave her the order for her bone density to hand to the front desk clerical staff. 
Upon Dorothy’s return to the clinic a few months later, she handed me another list of blood pressures that she had taken at home, and again they were in the normal range.
“Very good, Dorothy,  I see you got your bone density scan done several weeks ago.  Unfortunately, it shows that you have osteoporosis, which means that you’re at an increased risk for fracturing a bone.  Your Z score is a negative 2.5.  That means in comparison to a normal healthy 20-30 year old woman your bone density shows very little density and probably a lot of empty holes in your bones.  We need to get your started on a medication that you can take once a week to help your bones re-build themselves.”
“I thought my being on calcium and Vitamin D was all I needed to address that.  Why do I need to take an additional medicine over the calcium with D supplement I already take?”
“Well if you don’t take it, you’ll be facing the risk of having a major fracture, especially a hip fracture from just tripping over a chair leg for instance, or catching your shoe on a piece of carpet.  Calcium and  Vitamin D are important and they certainly play a role in helping to keep your bones strong, but for some women they need additional help, which is where you are.”
“So you’re telling me that if I don’t take this medicine I could break my hip or something?”
“Yes.”
“Hmm, that reminds me,  I remember my grandmother fell down and broke her hip, she ended up in a nursing home where she died about 6 months later from a blood clot.  That’s not how I want to go.  So tell me about the weekly medicine I have to take and what it will do for me.”
I proceeded to tell her about the weekly pill she would have to take, the side effects to it and that we would do a repeat bone scan on her in two years to assess her response.

Osteoporosis is a common disease among the elderly population.  It is more common among women than men and by the time it is diagnosed is has been present for many years.  It takes years for it to develop, the patient’s bone slowly depletes bone deposition, and over time the patient’s bone become brittle and easy to break because there is almost nothing left in them to give them strength and prevent any possible fracture. 
A part of the reason that women have this disease more than men is that they lose their estrogen production after menopause and estrogen is one of the hormones that is responsible for making the bony matrix. 

About six months later I saw Dorothy again for a visit.  She needed to have her mammogram ordered and needed her blood pressure medication refilled.  I walked into the exam room to find her sitting on the exam table with the usual of her at-home blood pressure readings and a cast on her right arm.
“What happened to you?”
“I  fell down a bunch of stairs about two weeks ago.  My high heel shoes I was wearing caught the edge of the step and I fell forward, I heard a crack and looked down at my arm and knew it was broke, it was at this weird angle.  I also bruised my leg and rib cage pretty badly, in fact the bruises have just gone away in the last couple of days.”
“Wow, I’m sorry to hear that.  So when do you go back to see the orthopedic surgeon?”
“I saw him a week ago, that’s when he took me out of the splint and put this cast on.  I have to go back and see him in another 3 weeks for him to take an x-ray of my arm to make sure that it is healing correctly.” 
“Oh my, it just makes me wonder how much worse it would have been had you not started your weekly medication for your bone density six months ago.”
"Yes, the bone doctor mentioned that.  He told me he was glad that I was on it, otherwise he told me the break most likely would have been worse.”
“Well, I like your blood pressure readings at home.  The reading here in the clinic is also fine so we’ll stay the course with your medication for it.  Let me listen to your lungs and heart and then I’ll give you an order slip for you to get your annual mammogram.”
“Fine with me.  Will you just let me know the results of the mammogram once it’s done?”
“Yes, you can expect something in the mail about a week after the mammogram is done.”
“Alright, well here’s your mammogram order, you can give it to the front desk clerical staff, they can schedule it for you.  I’m glad to see that you’re doing so well, and I hope your arm heals up nicely for you.”
“So do I.”
“I’ll see you back in six months.  Good luck with your arm.”
“Thanks.”

Preventive medicine is important.  Patients need to remember that taking care of themselves before a medical condition occurs is one of the best ways for them to prevent disease.  Patients need to remember that they need to be appropriately screened for colon cancer, breast cancer, stay on a nutritious diet, exercise, address your stress levels, and keep the weight off.  Doing those little things for yourself each and every day will pay off in the long run.  Stay at it, and remind your primary care provider if they forget to schedule you for an appropriate screening.    

2 comments:

  1. Can you tell me the name of the medication you recommend for osteoporosis? Can I get a bone density test at age 43, do you know?
    Thanks for another interesting article!

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