Subjective
Date of visit
Reason for visit (initial evaluation for suspected osteoporosis, follow-up for diagnosed osteoporosis)
History of present illness:
Any history of fractures (particularly fragility fractures) – a major red flag for osteoporosis
Back pain (may be present, but not specific for osteoporosis)
Height loss (may be a sign of vertebral fractures)
Past medical history:
Age at menopause
Use of hormone replacement therapy (HRT) – can help prevent bone loss
Risk factors for osteoporosis (family history, ethnicity, low calcium intake, weight loss, smoking, excessive alcohol use)
Previous use of medications that can weaken bones (corticosteroids)
Underlying medical conditions that can contribute to osteoporosis (rheumatoid arthritis, hyperthyroidism)
Medications (current medications, calcium and vitamin D supplements)
Allergies (allergies to medications)
Social History
Lifestyle habits (smoking, alcohol intake, exercise)
History of falls (increased risk of fractures in osteoporosis)
Family History
Family history of osteoporosis or fragility fractures
Objective
Vital signs (temperature, blood pressure) – may be normal unless there’s an underlying condition
Physical exam:
General (assessing for signs of kyphosis – dowager’s hump)
Musculoskeletal exam:
Assess for tenderness or deformity of the spine
Limited range of motion (may be present with pain)
Neurological exam (brief exam to assess for nerve compression if fractures are suspected)
Assessment
Suspected postmenopausal osteoporosis based on risk factors and clinical presentation
Consideration of diagnostic workup (may include some of the following):
Bone density scan (DXA scan) – the gold standard for diagnosing osteoporosis
Laboratory tests (calcium, vitamin D levels, other tests to rule out secondary causes)
Severity of osteoporosis (based on bone density T-score)
Plan
Confirmation of osteoporosis diagnosis with bone density scan (if not already done)
Treatment for osteoporosis (aimed at preventing fractures and preserving bone density):
Lifestyle modifications:
Calcium and vitamin D supplementation
Weight-bearing exercise (to stimulate bone formation)
Smoking cessation
Fall prevention strategies
Medications:
Bisphosphonates (alendronate, risedronate) – the mainstay of treatment
Other options (estrogen therapy, SERMs, denosumab) – considered based on individual factors
Education
Explain osteoporosis, its causes, risk factors, and potential complications (fractures).
Discuss the importance of calcium and vitamin D for bone health.
Benefits of weight-bearing exercise and fall prevention strategies.
Review the treatment plan, including medications and potential side effects.
Importance of medication adherence and regular follow-up for monitoring bone density and response to treatment.
Follow-up
Schedule for follow-up appointments:
Monitor for response to treatment (repeat bone density scan at intervals)
Adjust treatment plan as needed
Address any pain or other symptoms related to osteoporosis
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of postmenopausal osteoporosis.