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A 56-year-old woman gravida 5 para 4 aborta (spontaneous) 1 is under evaluation for laboratory results obtained 2 weeks ago. Onset of menses was at age 16 years and her first pregnancy was at age 22 years. Onset of menopause was 2 years ago. Medical history is benign. The woman’s maternal grandmother died of breast cancer at age 78 years and her sister suffers from systemic lupus erythematosus (SLE). There is no smoking or drinking history. Activity is one mile of walking 5 to 6 mornings per week. Diet is dairy product restricted by the patient because of lactose intolerance. Medications are over the counter vitamin and mineral supplements including vitamin D 800 IU per day and oyster shell calcium 1500 mg per day. Vital signs and physical examination is normal. The laboratory values from 2 weeks ago are shown below. A dual-energy x-ray absorptiometry performed 2 days ago shows T scores at the lumbar spine and left proximal femur of - 2.3 and -2.7 respectively. What is the next best step in management?

Serum electrolytes:

Sodium:


139 mEq/L

Potassium:


4.5 mEq/L

Chloride:


105 mEq/L

Bicarbonate:


28 mEq/L

Calcium (total):


11.0 mEq/dL

Phosphate:


2.2 mEq/dL

Magnesium:


1.5 mEq/L

Blood glucose (random):


85 mg/dL

Alanine aminotransferase (ALT):


4 U/L

Aspartate aminotransferase (AST):


2 U/L

Alkaline phosphatase:


205 U/L

Lactate dehydrogenase:


90 U/L

Bilirubin, total:


1.2 mg/dL

Amylase:


25 U/L

Lipase:


10 U/L

Blood urea nitrogen (BUN):


16 mg/dL

Serum creatinine:


0.8 mg/dL

Serum uric acid:


female 5.5 mg/dL

Hemoglobin (Hb):


14 g/dL

Hematocrit (Hct):


42%

Platelets:


170

White blood count (WBC):


5.8k/uL

Neutrophils:


60%

Lymphocytes:


37%

Total cholesterol:


185 mg/dL

Low density lipoprotein (LDL):


114 mg/dL

High density lipoprotein (HDL):


45 mg/dL

Triglycerides:


130 mg/dL

T4 (thyroxine):


8 ug/dL (8)

Thyroid-stimulating hormone (TSH):


1.5 mU/L

Intact serum parathyroid hormone (PTH):


95 pg/mL

Erythrocyte sedimentation rate (ESR):


5 mm/hr

Fibrinogen:


250 mg/dL

A. Advise the patient to discontinue her calcium supplements
B. Consult a surgeon to schedule parathyroid surgery
C. Order computed tomography (CT) of the chest
D. Prescribe bisphosphonates once a week
E. Prescribe hormone replacement therapy

Very good one! Don't have the precise answer. Just thoughts.
It's not B. She does not need surgery, her PTH is low.
Not E. Hormone replacement therapy is not the first line in the treatment of osteoporosis. Plus slightly elevated bilirubin and breast cancer in the history.


So A, C or D. Patient have osteoporosis. T score-2.7 ( T-score between -1 and -2.5 is diagnosed as osteopenia. A score of -2.5 or below is diagnosed as osteoporosis). But elevated alkaline phosphataseis not typical for osteoporosis.
She has elevated Ca
low phosphates, magnesium and PTH
Elevated bilirubin and LDL

I cant put everything together