Osteoporosis Consultation

OVERALL_INSTRUCTIONS

Chief Complaint

Osteoporosis Consultation

Template

Thank you for asking me to see [name] regarding osteoporosis. She is a [age]-year-old. She is referred because of [indicate reason for referral]. [indicate whether or not she has had a fracture, year and location of fractures.] She is a G[gravidity]P[parity] who had menopause at age [age of menopause]. [indicate whether or not she used hormone therapy and for how long] We discussed secondary causes of osteoporosis. [Indicate whether there is a history of steroid use or not.] [Whether there is any history of rheumatoid arthritis or not.] [Indicate whether there is a history of bowel complaints, celiac, malabsorption or not.] [Indicate whether there is a history of cigarette smoking, and for how long and when, and indicate if a non smoker.] [Indicate how many cups of coffee she drink per day and whether decaf or not.] [Sentence about whether she has lost height from her maximum and how much.] Sentence about her weight and whether it has increased or decreased or been stable, and change by how much.] [Sentence about what exercise and activity she reports, how often for how long or whether she does not exercise]. She takes [number] units of vitamin-D daily and has dietary intake of calcium as well as about [number] mg per day in supplements. [Sentence about Whether or not there is a family history of osteoporosis, in whom, and whether they have broken a hip] PAST MEDICAL HISTORY: document any medical conditions in bullet list SURGERIES: document any surgeries including biopsies and small procedures MEDICATIONS: list any prescription and non prescription medications in a bullet list ALLERGIES: indicate any allergies or if no allergies write "NKDA" SOCIAL HISTORY: Indicate social history of occupation, where they lives and with whom, whether retired, what their activities are. PHYSICAL EXAMINATION: Enter the patients height and weight and calculate the BMI.[ document general exam if performed] Investigations: [Results of lab work] [results of any X-rays if done] Bone density T-scores at the spine, total hip and femoral neck and indicate year and month the study was done. [note any change, improvement in the bone density in percent] [Previous bone density score if discussed and year that they were done.] [results of any additional tests including CT, MRI etc] [If discussed, indicate the FRAX percent risk of any fracture and hip fracture over 10 years] Summary: Summarize the patient complaint and key points in history related to osteoporosis and osteoporosis risks. Plan: [bullet point the plan for medication, exercise, diet, vitamins and plan for follow up.]