Low back pain and waddling gait in a 60-year-old woman
A 60-year-old woman comes to your office with complaints of low back pain, which is causing progressive difficulty in walking. The pain has gradually increased since the onset of menopause 5 years ago. This discomfort is especially noticeable after prolonged sitting.
Social history reveals that the patient has been a housewife since her marriage 38 years ago. Her husband, who is in good health, owns and operates a small retail shop in their home. The patient has been making jewelry for sale in her husband’s shop and as a hobby for about 35 years. They have two adult sons who are in good health.
The patient denies a personal or family history of kidney disease, hypertension, diabetes mellitus, or cardiovascular disease; she also denies history of back trauma or weight loss. She has smoked one to two packs of cigarettes a day for the past 40 years. She does not take estrogens, calcium supplements, vitamins, or other medications.
On examination you find a thin female with a slightly stooped posture and a waddling gait. Blood pressure is 120/70. Her teeth have a yellow discoloration above the crown, and her fingernails are stained with nicotine. She is anosmic on cranial nerve examination. Results of cardiovascular and abdominal examination are normal. The lower lumbar spine is tender to percussion, but the patient does not complain of pain on straight leg raising. Her deep tendon reflexes are intact, and the remainder of the physical examination, including neurologic testing, is normal. Sensation and strength are normal in legs and feet. Range of motion is normal in hips and knees.
Initial laboratory data include a urinalysis showing 3+ proteinuria and glycosuria. BUN, creatinine, and albumin levels are normal. Roentgenograms of the pelvis and lumbosacral spine reveal pseudofractures and other evidence of severe osteomalacia and mild osteoporosis. There are no osteolytic or osteoblastic lesions.
(a) What should be included on the patient’s problem list?
(b) What additional information would be helpful in diagnosing this woman’s condition?
(c) What further tests, if any, would you recommend?
(d) What treatment would be appropriate for this patient?
Answers to the Pretest are included in Challenge answers (6) through (9) on page 19.