Osteoporosis Consult

Finished note

Example — generated by Notat from a sample visit

Reason for consultation:
Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope.

Assessment:
Stable clinical presentation requiring further outpatient evaluation.

Plan:
Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Dear Dr. [Referring physician name],

I had the pleasure of seeing your patient today in consultation for assistance with [reason for consultation].

Past medical history:
(hyphenated list)
- [Relevant past medical history]

Fracture history:
(hyphenated list)
- [Previous fractures and details]

Medications:
(hyphenated list)
- [Current medications]
- [Medications in the past relevant to bone health]

Allergies:
(hyphenated list)
- [Known allergies]

Habits:
(hyphenated list)
- [Relevant habits such as caffeine, alcohol, and smoking]

Social:
(hyphenated list)
- [Relevant social history]

Family history:
(hyphenated list)
- [Family history of hip fracture, vertebral fracture, or osteoporosis]

History of presenting illness:
[Details of presenting illness]
[Risk factors for osteoporosis]
[Dietary calcium intake]
[Menopausal history]
[Previous treatment for osteoporosis]

Physical examination:
- Height: [Patient's height]
- Weight: [Patient's weight]
- Ribbed pelvis distance: [Ribbed pelvis distance measurement]
- Occiput to wall: [Occiput to wall measurement]

Investigations:
(hyphenated list)
- [Relevant investigations]

Impression and plan:
(hyphenated list)
- [Assessment for secondary causes with specific blood work]
- [Vertebral x-ray]
- [Treatment plan]
- [Calcium and vitamin D]
- [Follow-up on mineral density test]
- [CAROC and FRAX calculation]