Start your consultation note with a formal greeting and state the purpose of the visit. For example:

Dear Dr. Smith,

I had the pleasure of seeing your patient today in consultation for assistance with osteoporosis management.

Detail the patient's relevant medical history, focusing on conditions that affect bone health. For instance:

The patient has a history of rheumatoid arthritis and hypertension.

Specify any previous fractures, which are critical in assessing osteoporosis risk:

The patient experienced a wrist fracture in 2018 and a vertebral fracture in 2020.

List current and past medications, highlighting those impacting bone health:

Current medications include Alendronate, Methotrexate, and Lisinopril. Past medications relevant to bone health include Calcium supplements.

Document any known allergies to prevent adverse reactions:

The patient is allergic to penicillin.

Include lifestyle factors and social background that could influence health:

The patient consumes alcohol occasionally and does not smoke. The patient is a retired school teacher and lives with her spouse.

Family medical history helps assess genetic risk factors:

There is a family history of osteoporosis in the patient's mother and a hip fracture in her grandmother.

Provide a detailed account of the current symptoms and related medical history:

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.

Record physical exam findings relevant to osteoporosis:

Height: 165 cm, Weight: 70 kg, Ribbed pelvis distance: 2 cm, Occiput to wall: 5 cm.

Discuss any diagnostic tests performed and their results:

Recent DEXA scan shows a T-score of -2.5 at the lumbar spine.

Summarize your assessment and outline the management 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.

Conclude with a formal closing:

Thank you for the referral.

Sincerely,

Dr. Emily Johnson, MD

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