Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 55-year-old woman is evaluated for a new-patient visit. Medical history is significant for an eating disorder. Although she has maintained a normal weight for the past 20 years, she notes that prior to that time her weight would fluctuate in a range correlating with BMIs of 17 to 19. She has otherwise been healthy and currently feels well. She is postmenopausal and a never-smoker. Family history is significant for postmenopausal osteoporosis in her mother. Her medications are over-the-counter calcium and vitamin D supplements.
On physical examination, temperature is 36.3 °C (97.3 °F), blood pressure is 137/81 mm Hg, pulse rate is 76/min, and respiration rate is 11/min. BMI is 21. She has mild thoracic kyphosis but no skeletal tenderness. The remainder of the examination is unremarkable.
Results of laboratory studies are significant for a serum calcium level of 9.1 mg/dL (2.3 mmol/L) and 25-hydroxyvitamin D level of 40 ng/mL (99.8 nmol/L); thyroid function studies are normal.
Dual-energy x-ray absorptiometry (DEXA) scan shows T-scores of –1.8 in the femoral neck and –1.9 in the lumbar spine. Ten-year fracture risk using the Fracture Risk Assessment Tool (FRAX) is 6.9% for major osteoporotic fracture and 0.7% for hip fracture. Plain radiographs of the spine show no evidence of compression fracture.
Which of the following is the most appropriate management of this patient?
A. Begin raloxifene
B. Repeat DEXA scan in 2 years
C. Replace calcium with cholecalciferol
D. Start bisphosphonate therapy
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