orthopedic dictation key

ORTHOPEDICS FOLLOWUP NOTE

HISTORY/PRESENT ILLNESS: This patient is a XX-year-old referred to me for osteopenia. Since his last visit, he has been on calcium supplements; I added Fosamax to that. I requested a 24-hour urine and an osteocalcin. He is a severe chronic obstructive pulmonary disease patient. He, nor his wife, recalls ever requiring any steroids.

LABORATORY DATA: His most recent labs which were reviewed reveal calcium 10 normal, thyroid stimulating hormone 1.31 normal, osteocalcin suppressed at 2.6, indicating decreased bone turnover. The patient has not had any parathyroid hormone done; it will be done next time. His 24-hour urine for calcium was 250, but his phosphorus was 400 mg, indicating low phosphorus excretion. Osteocalcin is the clincher and he has been on Fosamax for 2 months.

He may be a candidate for teriparatide and it is non-formulary; I would request the pharmacy committee to consider this since he is at high-risk for fractures. The patient also, since his last visit, ended up in a hospital for cardiac reasons. They wanted to do angioplasty but could not go through the groin femoral, so they had to do atherectomy on both sides and angioplasty. He is walking, feeling fairly well otherwise.

PHYSICAL EXAMINATION:

VITAL SIGNS: Normal.

HEENT: Head normocephalic; nose normal; throat clear; teeth, tongue, gums normal.

NECK: Supple.

LUNGS: Chest is normal shape, symmetrical with good expansion. Lungs clear on auscultation.

HEART: Regular rhythm. No murmurs.

ABDOMEN: Soft, nontender. No hepatosplenomegaly.

MUSCULOSKELETAL: Joints normal. Peripheral pulsations normal.

SKIN: Normal.

EXTREMITIES: No edema.

NEUROLOGICAL: Cranials intact; motor sensory normal; reflexes normal.

ASSESSMENT: Osteoporosis, other associated conditions like type 2 diabetes, history of severe smoking before, and chronic obstructive pulmonary disease.

RECOMMENDATIONS: He might be need cycling of parathyroid hormone along withbisphosphonates and calcium supplements to help his bone regeneration. The patient is to be seen and followed.

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