Symptoms and signs

The history and physical examination are important in screening for secondary forms of osteoporosis and directing the evaluation, although they are neither sensitive enough nor sufficient for diagnosing primary osteoporosis. A medical history provides valuable clues to the presence of chronic conditions, behaviors, physical fitness, and/or the use of long-term medications that could influence bone density. Patients already affected by complications of osteoporosis may complain of upper or mid-thoracic back pain associated with activity, aggravated by long periods of sitting or standing, and easily relieved by rest in the recumbent position. Low bone density, a propensity to fall, greater height, and presence of previous fractures confer increased fracture risk.

Table 14.2 Indications for measuring bone density

Concerned perimenopausal woman willing to start therapy

Radiographic evidence of bone loss

Patient on long-term glucocorticoid therapy (more than one month at >7.5 mg prednisone/day)

Asymptomatic hyperparathyroidism, where osteoporosis would suggest parathyroidectomy

Monitoring therapeutic response in woman undergoing treatment for osteoporosis if the result of the test would affect the clinical decision

A thorough physical examination is important for the same reasons. Lid lag and/or enlargement or nodularity of the thyroid suggests hyperthyroidism. Moon facies, thin skin, and a buffalo hump suggest hypercortisolism. Cachexia mandates screening for an eating disorder or malignancy. A pelvic examination is one aspect of the total evaluation of hormonal status and a necessary part of the physical examination in women. Osteoporotic fractures are late physical manifestations. Common fracture sites are the vertebrae, forearm, femoral neck, and proximal humerus. The presence of a dowager's hump in elderly patients indicates multiple vertebral fractures and decreased bone volume.

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