Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Back pain (consider characteristics – sharp, achy, radiating, worse with activity)
Loss of height
Bone fracture (if present)
II. History of Present Illness:
Onset and duration of symptoms
Severity and limitations due to pain (functional limitations)
Previous fractures ( atraumatic or fragility fractures)
Dose and duration of corticosteroid therapy (type of steroid)
Reason for corticosteroid use (underlying condition)
III. Past Medical History:
Underlying conditions requiring corticosteroid therapy (e.g., autoimmune diseases, chronic obstructive pulmonary disease (COPD), asthma)
Other risk factors for osteoporosis (family history, previous fractures, low calcium intake, vitamin D deficiency)
IV. Medications:
Current medications (corticosteroids, calcium supplements, vitamin D supplements, bisphosphonates)
V. Social History:
Smoking history (current or past smoker)
Alcohol intake
Physical activity level
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp)
General appearance (kyphosis – hunched posture suggestive of vertebral fractures)
Musculoskeletal exam:
Back tenderness on palpation (localize to specific area if possible)
Limited range of motion of the spine
Height measurement (consider comparing to prior measurements if available)
VII. Diagnostic Studies (consider as appropriate):
Dual-energy X-ray absorptiometry (DXA scan) to assess bone mineral density (BMD) at the hip and spine (essential for diagnosis)
Vertebral fracture assessment with X-ray or vertebral morphometry (optional)
VIII. Assessment:
Confirmed or suspected corticosteroid-induced osteoporosis based on clinical presentation, history of corticosteroid use, and BMD findings (T-score) on DXA scan.
Severity of bone loss (osteopenia or osteoporosis)
Risk of future fractures
IX. Plan:
Treatment plan focuses on:
Reducing corticosteroid dose if possible: Discuss with the provider managing the underlying condition for potential dose reduction or alternative treatments.
Lifestyle modifications:
Weight-bearing exercise program to improve bone strength
Smoking cessation (if applicable)
Adequate calcium intake (diet and supplements)
Vitamin D supplementation (to optimize calcium absorption)
Medications:
Bisphosphonates (alendronate, risedronate) – to inhibit bone resorption and increase BMD
Other osteoporosis medications (consider in specific cases) – discuss with healthcare provider
X. Prognosis:
Discuss the potential for improvement in bone density with treatment and the importance of adherence to recommendations.
Address the risk of future fractures and the importance of fall prevention strategies.
XI. Notes:
Include any additional observations or concerns, such as patient’s understanding of the diagnosis and treatment plan, pain management strategies, and need for physical therapy referral.
XII. Resources:
Consider providing patient education materials on corticosteroid-induced osteoporosis from reputable sources (e.g., National Osteoporosis Foundation, American College of Rheumatology).