CASE INFORMATION

Case ID: BONE-2025-008
Case Name: Margaret Thompson
Age: 68 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L95 (Osteoporosis)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and communicates effectively 1.2 Elicits patient concerns and expectations 1.5 Provides clear education about osteoporosis and fracture prevention
2. Clinical Information Gathering and Interpretation	2.1 Obtains a thorough history including risk factors 2.3 Interprets bone mineral density (BMD) results 2.4 Identifies secondary causes of osteoporosis
3. Diagnosis, Decision-Making and Reasoning	3.2 Diagnoses osteoporosis based on clinical criteria and investigations 3.4 Determines fracture risk using appropriate assessment tools (e.g., FRAX, Garvan)
4. Clinical Management and Therapeutic Reasoning	4.1 Provides evidence-based pharmacological and non-pharmacological management 4.3 Prescribes bisphosphonates and other osteoporosis treatments when indicated 4.6 Implements falls prevention strategies
5. Preventive and Population Health	5.1 Discusses lifestyle modifications to optimise bone health
6. Professionalism	6.2 Demonstrates patient-centred care and shared decision-making
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and follow-up plans
8. Procedural Skills	8.1 Orders and interprets DXA scan results appropriately
9. Managing Uncertainty	9.1 Identifies patients requiring specialist referral (e.g., endocrinology, rheumatology)
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and manages complications of osteoporosis (e.g., vertebral fractures)

CASE FEATURES

Elderly female presenting for a routine check-up, with a recent minor fall but no fracture.
Has postmenopausal status, low body weight, and a family history of hip fractures.
Reports mild back pain and height loss, raising suspicion of undiagnosed vertebral fractures.
Requires osteoporosis risk assessment, lifestyle advice, and discussion about pharmacological treatment.

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Margaret Thompson
Age: 68 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Pantoprazole 40 mg daily for reflux
Paracetamol PRN for mild back pain

Past History

Menopause at age 50
GORD (Gastroesophageal reflux disease)
No previous fractures

Social History

Lives independently at home, but concerns about balance issues.
Non-smoker, consumes 1-2 glasses of wine per week.
Diet low in dairy, minimal weight-bearing exercise.

Family History

Mother had a hip fracture at age 72.

Smoking

Non-smoker

Alcohol

1-2 standard drinks per week

Vaccination and Preventative Activities

Up to date with influenza, pneumococcal, and COVID-19 vaccines

SCENARIO

Margaret, a 68-year-old woman, presents for a routine check-up. She mentions a recent fall while gardening, landing on her side but without fractures. However, she reports mild, persistent back pain and has noticed a gradual loss of height.

She has never had a DXA scan and is unsure if she needs osteoporosis screening. She is also concerned about osteoporosis medications and their side effects.

EXAMINATION FINDINGS

General Appearance: Well, no distress.
Height: 4 cm shorter than recorded at age 50.
Spine Examination:

Mild thoracic kyphosis
Localized tenderness over T8-T10
No focal neurological deficits

Gait and Balance:

Mild unsteadiness on tandem walking
No use of mobility aids

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What key aspects of history would you explore further to assess Margaret’s osteoporosis risk?

Prompt: Ask about dietary calcium intake, physical activity, and falls history.
Prompt: Assess for secondary causes of osteoporosis (e.g., long-term corticosteroid use, thyroid disease).

Q2. What are the most likely diagnoses, and what features support your conclusion?

Prompt: Discuss why osteoporosis is the most likely diagnosis.
Prompt: Consider other causes of back pain (e.g., osteoarthritis, vertebral fractures, malignancy).

Q3. What investigations would you order to confirm the diagnosis and assess risk?

Prompt: Discuss DXA scan for bone mineral density and vertebral fracture assessment.
Prompt: Identify additional tests for secondary causes (e.g., calcium, vitamin D, thyroid function, renal function).

Q4. What are the key components of management, including pharmacological and non-pharmacological strategies?

Prompt: Discuss bisphosphonates as first-line treatment, calcium and vitamin D supplementation.
Prompt: Explain falls prevention strategies and lifestyle modifications.

Q5. How would you counsel Margaret on osteoporosis treatment, prognosis, and monitoring?

Prompt: Provide realistic expectations regarding treatment efficacy and adherence.
Prompt: Address concerns about medication risks (e.g., bisphosphonate side effects, atypical fractures).

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What key aspects of history would you explore further to assess Margaret’s osteoporosis risk?

A thorough history is crucial to assess osteoporosis risk factors, secondary causes, and fracture risk.

1. Osteoporosis Risk Factors

Menopause history: Age at menopause (earlier onset increases risk).
Lifestyle factors: Dietary calcium intake, weight-bearing exercise, smoking, alcohol intake.
Medication history: Long-term use of corticosteroids, proton pump inhibitors (e.g., pantoprazole), or anticonvulsants.
Falls history: Recent falls, near-misses, frequency, and circumstances.

2. Fracture Risk Assessment

History of previous fractures: Especially minimal trauma fractures (e.g., wrist, vertebral, hip).
Height loss and back pain: May indicate vertebral compression fractures.
Family history: Hip fractures in a first-degree relative increase risk.

3. Secondary Causes of Osteoporosis

Endocrine disorders: Hyperthyroidism, hyperparathyroidism, vitamin D deficiency.
Chronic diseases: Rheumatoid arthritis, coeliac disease, chronic kidney disease.

4. Functional and Social Impact

Impact on mobility, independence, and concerns about fracture risk.
Understanding of osteoporosis and willingness to consider treatment.

A detailed history guides risk assessment, appropriate investigations, and preventive strategies.

Q2: What are the most likely diagnoses, and what features support your conclusion?

1. Osteoporosis – Most Likely Diagnosis

Postmenopausal status and risk factors: Age >65, low dairy intake, family history of hip fractures, previous fall.
Height loss and back pain: Suggests vertebral compression fractures.
Chronic proton pump inhibitor (PPI) use: Long-term pantoprazole may contribute to bone loss.

2. Differential Diagnoses

Osteopenia: If BMD T-score is between -1.0 and -2.5.
Osteomalacia: If vitamin D deficiency and bone pain are present.
Spinal osteoarthritis: If localised back pain without vertebral collapse.

Given Margaret’s risk factors, clinical features, and vertebral changes, osteoporosis is the most likely diagnosis.

Q3: What investigations would you order to confirm the diagnosis and assess risk?

1. Bone Mineral Density (BMD) Scan

DXA scan of lumbar spine and hip:
- T-score ≤ -2.5 confirms osteoporosis.
- T-score -1.0 to -2.5 suggests osteopenia.

2. Fracture Risk Assessment

FRAX or Garvan Fracture Risk Calculator:
- Estimates 10-year risk of major osteoporotic and hip fractures.

3. Secondary Causes Screening

Serum calcium, phosphate, vitamin D – Identifies osteomalacia or hyperparathyroidism.
Thyroid function tests – Hyperthyroidism increases bone turnover.
Renal function (eGFR, creatinine) – CKD affects bone metabolism.

4. Vertebral Fracture Assessment

Spinal X-ray (if height loss or persistent back pain) to identify vertebral compression fractures.

These investigations confirm osteoporosis, assess fracture risk, and exclude secondary causes.

Q4: What are the key components of management, including pharmacological and non-pharmacological strategies?

1. Lifestyle Modifications

Calcium intake: Aim for 1,200 mg daily (diet + supplements if needed).
Vitamin D: 800–1,000 IU/day, especially if deficient.
Weight-bearing exercise: Walking, resistance training to maintain bone mass.

2. Falls Prevention

Home modifications (non-slip mats, better lighting).
Balance exercises (e.g., Tai Chi, physiotherapy referral).

3. Pharmacological Treatment

First-line: Bisphosphonates (alendronate 70 mg weekly or risedronate 35 mg weekly).
Alternative if intolerant: Denosumab (6-monthly injection).
High-risk cases: Teriparatide (if severe vertebral fractures).

4. Monitoring and Follow-Up

Repeat DXA scan in 2 years to assess treatment response.
Monitor for bisphosphonate side effects (e.g., atypical femoral fractures, osteonecrosis of the jaw).

This comprehensive plan reduces fracture risk and preserves bone health.

Q5: How would you counsel Margaret on osteoporosis treatment, prognosis, and monitoring?

1. Explain the Diagnosis and Risks

Osteoporosis increases fracture risk, but treatment significantly reduces this.
Early intervention prevents serious fractures (e.g., hip, vertebral).

2. Address Treatment Options

Bisphosphonates are first-line and reduce fracture risk by 40–50%.
Address concerns about side effects (e.g., osteonecrosis of the jaw is rare).
Regular follow-up is essential to assess response and adjust treatment if needed.

3. Reinforce Lifestyle Strategies

Daily calcium and vitamin D intake is crucial.
Regular weight-bearing exercise improves bone strength.
Falls prevention strategies reduce injury risk.

4. Set Expectations for Monitoring

DXA scan every 2 years to track bone density changes.
Reassess fracture risk and treatment adherence regularly.

Providing clear, evidence-based education supports informed decision-making and long-term adherence.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, covering osteoporosis risk factors, falls history, and secondary causes.
Correctly diagnosing osteoporosis, differentiating from osteopenia and osteomalacia.
Ordering appropriate investigations, including DXA scan, FRAX/Garvan risk assessment, and blood tests.
Evidence-based management, including bisphosphonates, calcium/vitamin D, exercise, and falls prevention.
Effective patient education, addressing treatment adherence, prognosis, and lifestyle modifications.

PITFALLS

Failing to assess secondary causes, leading to missed treatable conditions (e.g., vitamin D deficiency, thyroid disease).
Not using a validated fracture risk tool (FRAX/Garvan) to guide treatment decisions.
Overlooking lifestyle factors, particularly calcium, vitamin D, and exercise recommendations.
Poorly addressing patient concerns about medication side effects, reducing adherence.
Delaying bisphosphonate therapy despite high fracture risk.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD