History of present illness:
Patient is a 67 year old thin Caucasian female presenting to her family practitioner with the main complaints of decreasing strength and moderate back pain that radiates from the back to the sides of the her body.
Past medical history
Irritable bowel disease.
Right foot stress fracture last year while stepping off a small bench.
Family history
Father dies of a heart attack at age 80.
Mother has a history of Osteoporosis.
Social History
Patient smoked 2 packs a week from age 25-50.
Patient has a long history of alcohol use and abuse from age 20 to 45. She frequently got drunk during social occasions as well as during gatherings, as often as once a week. She stopped drinking 13 years ago.
Sedentary life style
Allergies
None
Medications
Multivitamins
Calcium 1200 mg/day
Key Labs, images, or procedures performed in relation to current diagnosis.
Bone Density: T score of -3.1
Estrogen levels: <30 pg/mL (decrease)
Key Physical Examination findings:
Mild hunchback appearance with an accompanying stooped posture.
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