A 60-year-old woman with low back pain and waddling gait.
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 graduallyincreased since the onset of menopause five 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 neurological 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. Blood urea nitrogen (BUN), creatinine, and albumin levels are normal. Radiographs of the pelvis and lumbosacral spine reveal pseudofractures and other evidence of severe osteomalacia and mild osteoporosis. There are no osteolytic or osteoblastic lesions.
The patient maintains a jewelry fabricating and engraving area in the basement of her home where she uses abrasive grinders, engraving equipment, soldering tools, and various raw materials. She does not use a dust mask but does wear a face shield when operating the grinder. The work area is dusty, with only two small windows near the top of one wall capable of providing ventilation. There is no local or general mechanical exhaust system. She admits to smoking and eating in the work area. The patient and her husband also tend a small garden in the backyard in which they grow vegetables for the table. A nearby wastewater treatment plant provides free fertilizer, which her husband applies to the garden every few weeks. The garden is irrigated with water from a municipal well.
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