From the foregoing discussion, it is clear that a major part of the initial evaluation of the patient with known or suspected osteoporosis is to obtain an accurate history that might provide clues as to possible secondary causes, as well as assess existing genetic, lifestyle, and other risk factors that might impact on fracture risk. The key elements of the history and examination that need to be assessed are summarized in Table 3.
Table 3. Important elements of the medical history and physical examination in the evaluation of the patient with osteoporosis. Adapted from (6), with permission.
|
Skeletal history |
Fractures, pain, deformity, reduced mobility, height loss |
|---|---|
|
Risk-factor assessment |
|
|
Family history |
Osteoporosis, fractures, renal stones |
|
Medical history |
|
|
Reproductive |
Women: Menarche > age 15 years, oligo/amenorrhea, menopause Men: Medical or surgical castration, changes in sexual function |
|
Medical disease |
Renal, GI, endocrine, rheumatic, or neurologic diseases;eating disorder; depression; prolonged immobilization |
|
Surgery |
Gastrectomy, small bowel resection, intestinal bypass, organ transplant |
|
Medications |
Glucocorticoids, anticonvulsants, cytotoxic agents, GnRH agonists, heparin, lithium |
|
Lifestyle and exercise |
Smoking, ETOH intake, frequent dieting, poor nutrition and exercise |
|
Diet and supplements |
Calcium (see Table 4), protein, vitamins D and A, caffeine |
|
Current medications |
Nonprescription drugs, hormones (estrogen, thyroid, glucocorticoids), sedatives or narcotics, antihypertensives, diuretics |
|
Review of systems/physical examination |
|
|
Weight loss, diarrhea |
Thyrotoxicosis, malabsorption |
|
Weight gain, hirsutism |
Cushing's syndrome |
|
Muscle weakness |
Cushing's syndrome, osteomalacia |
|
Bone pain |
Osteomalacia, hyperparathyroidism, malignancy, fractures |
|
Tooth loss |
Hypophosphatasia |
|
Joint or lens dislocations |
Abnormalities of collagen |
|
Skin rash/pigmentation/ stria |
Mastocytosis, hemochromatosis, Cushing's syndrome |
|
Nephrolithiasis |
Hypercalciuria, hyperparathyroidism |
It is important to assess the prior history of fractures, since even having a single vertebral fracture greatly increases the risk of subsequent fractures (7, 7a). Since osteoporosis has a strong genetic component, a family history of the disorder is a significant risk factor for the development of disease. Taking a reproductive history in women and searching for symptoms of hypogonadism in men is also critical. A history of other medical diseases impacting on bone may provide clues to possible secondary causes. Certain medications, as listed, are clearly associated with bone loss, and if possible, the overall length of exposure to these agents should be documented. Tobacco and alcohol exposure should be assessed, and some estimate of dietary calcium intake (diet plus supplements) should be obtained. Since about 75% to 80% of the calcium consumed in American diets is from dairy products, one can estimate total dietary calcium intake relatively easily. An 8-oz serving of milk contains approximately 300 mg of elemental calcium, an 8-oz serving of yogurt contains 400 mg of calcium, and a 1-oz serving of cheese contains 200 mg of calcium. Thus, simply by estimating the number of servings of various dairy products consumed by the patient, multiplying each by the above calcium contents, and adding these, one can arrive at a reasonably accurate total for calcium intake through dairy products. To this is added 250 mg for calcium from nondairy sources, as well as any supplemental calcium the patient may be taking. Finally, the review of systems and physical examination is focused on uncovering potential secondary diseases causing osteoporosis.