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Med Surg Case Study #5

Presenting Complaint: Mrs. Rodriguez, a 60-year-old female, presents to her primary care physician with complaints of recurrent fractures over the past year. She has experienced two wrist fractures and one vertebral compression fracture following minor falls.

Patient Background: Mrs. Rodriguez is a 60-year-old retired teacher. She has a history of hypertension and a 20-year history of smoking. She consumes alcohol occasionally and leads a sedentary lifestyle.

Assessment: Upon examination, Mrs. Rodriguez appears generally well. Her height has decreased by two inches over the last five years, and she reports a noticeable curvature of the spine.

1. Based on Mrs. Rodriguez's history and assessment findings, what is the possible diagnosis for his condition?

2. What diagnostics might be used to confirm the diagnosis?

3. What treatments might be needed for Mrs. Rodriguez's condition?

See answers below

Med Surg Notebook


1. What are the possible diagnoses for Ms. Anderson's condition?

  • The possible diagnosis for Mrs. Rodriguez's condition is osteoporosis, which is characterized by low bone mineral density and an increased risk of fractures, especially in postmenopausal women and individuals with risk factors such as smoking and sedentary lifestyle.

2. What diagnostics might be used to confirm the diagnosis?

  • Diagnostic tests used to assess Mrs. Rodriguez's bone health and risk of osteoporosis include the bone density scan (DXA) to measure bone mineral density and evaluate for osteoporosis. Clinical history and physical examination are also important components of the diagnostic process. Further assessments may include blood tests to measure calcium, vitamin D levels, and other bone health markers.

3. What treatments might be needed for Ms. Anderson's condition?

  • If Mrs. Rodriguez is diagnosed with osteoporosis, potential treatments may include medications to increase bone density, calcium and vitamin D supplementation, lifestyle modifications such as weight-bearing exercises, smoking cessation, alcohol moderation, and fall prevention strategies to reduce the risk of fractures.

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