STEP 1: READ
Patient History
Mai-jen Chou, is 64 years of age with a history of type 2 diabetes, asthma, hypertension, and degenerative joint disease. She presents to a general medicine clinic with persistent lower back pain. Her sister, Tian (age 68) has accompanied her to the clinic.Mai-jen reports that for the last few months, she has been experiencing aching pain in the lower lumbar area. It is worse with exertion. The pain is fairly localized, without radiation. She does not experience any tingling, numbness, or weakness. There is no history of trauma.
Mai-jen does exhibit some tenderness to palpation in the lower lumbar area. She notes that she tries to remain active, walking about 2 to 3 miles, 3 or 4 days a week; she is also a devoted gardener. She is concerned enough about this pain that she believes she needs an x-ray. She also reluctantly remarks that she is not sure if she is exaggerating, but she feels she might be “shrinking.” She recently tried on a pair of pants she purchased several years ago, and now they appear to be too long. She wants to know if this is possible. Tian recently told her that she was diagnosed with “brittle bones.”
Mai-jen has numerous risk factors for osteoporosis, including older age, female gender, and low body weight (she weighs 98 pounds and is 5’1” tall). She may also have a family history, and this should be explored further. Upon review of her medications, she has been treated with steroids for exacerbation of asthma, but there have been no such episodes in the past year. In addition, she is not on estrogen replacement therapy. The use of steroids and estrogen deficiency may be additional risk factors. Her level of physical activity is encouraging, but it does not offset her numerous risk factors.
Mai-jen lives alone in a two-story home. Mix of hardwood, carpets, vinyl for flooring. She shoveled snow during the last winter, but only twice. She then had a neighbor, Mike (age 36) and his son, Tom (age 10), shovel her driveway and sidewalk for her.
Mai-jen is a vegetarian, though will eat fish on rare, special occasions (holiday, birthday), along with some red or white wine. She loves fresh salads, tofu, soy alternatives (like soy “chicken” patties), and green tea and water to drink.
STEP 2: ANSWER THE QUESIONT IN DETAILS
The Questions
Household environmentquestions
Diet and exercisequestions
Family historyquestions
Co-morbidities/healthquestions
Medications/supplementsquestions
NOTE: List at least 4 questions of each category
