OSTEOPOROSIS EVALUATION Template

Dear Dr. Smith,
I had the opportunity to consult with your patient today regarding osteoporosis management.
Past medical history:
The patient has a history of rheumatoid arthritis and hypertension.
Fracture history:
The patient sustained a wrist fracture in 2018 and a vertebral fracture in 2020.
Medications:
Current medications include Alendronate, Methotrexate, and Lisinopril. Previous medications relevant to bone health include Calcium supplements.
Allergies:
The patient is allergic to penicillin.
Habits:
The patient occasionally consumes alcohol and does not smoke.
Social:
The patient is a retired school teacher and resides with her spouse.
Family history:
There is a family history of osteoporosis in the patient's mother and a hip fracture in her grandmother.
History of presenting illness:
The patient reports increasing back pain over the past six months. Risk factors for osteoporosis include long-term steroid use and post-menopausal status. Dietary calcium intake is low, and the patient has been post-menopausal for 10 years. Previous treatment for osteoporosis included bisphosphonates.
Physical examination:
height: 165 cm
weight: 70 kg
ribbed pelvis distance: 2 cm
occiput to wall: 5 cm
Investigations:
Recent DEXA scan shows a T-score of -2.5 at the lumbar spine.
Impression and plan:
Assessment for secondary causes with specific blood work including serum calcium, vitamin D, and thyroid function tests. Vertebral x-ray to assess for any new fractures. Treatment plan includes continuation of Alendronate, addition of vitamin D and calcium supplements. Follow-up on mineral density test in one year. CAROC and FRAX calculation indicate a high risk of fracture.
Thank you for the referral.
Sincerely,
Dr. Emily Johnson, MD