Osteoporosis

Low bone mass and microarchitectural deterioration leading to increased fracture risk. The diagnosis may be made clinically, or on bone densitometry scanning.

Is there a family history of osteoporosis, of broken hips or wrists, or of loss of height or a 'dowager's hump', with increasing age? 

A positive family history increases the risk of osteoporosis.

Does the patient smoke? 

Smoking increases the risk of osteoporosis.

Has the patient ever broken a bone? 

Osteoporosis is a risk factor for broken bones rather than a disease in itself.

If there is a history of broken bones, document the trauma involved to determine whether this was low impact and therefore of relevance or not.

Has the patient lost height? 

Loss of height indicates vertebral collapse, carrying the same risk of further fractures as acute vertebral collapses.

Does the patient have any history suggestive of hyperparathyroidism? 

Hyperparathyroidism is a recognised cause of osteoporosis. Ask about constipation, tiredness, depression, thirst, polyuria, renal stones, nausea and weight loss.

Does the patient have any history suggestive of Cushing's syndrome? 

Overt and sub-clinical Cushing’s syndrome increase the risk of developing osteoporosis. Ask about changes in appearance, skin, weight, blood pressure and diabetes.

Is the patient post menopausal? How early was their menopause? 

Premature menopause is an independent risk factor for osteoporosis.

What is the patient's contraceptive and menstrual history? 

Depot progesterone preparations and long periods of amenorrhoea are also associated with increased risk.

Are there any symptoms suggestive of pituitary disease, elevated prolactin or growth hormone deficiency? 

Hypopituitarism and growth hormone deficiency are risk factors for osteoporosis.

Long term hyperprolactinaemia also causes hypogonadism.

Are there any symptoms suggestive of hypogonadism: loss of libido, erectile dysfunction and loss of early morning erections, reduced muscle bulk or shaving frequency?

Hypogonadism of any cause is a risk factor for osteoporosis.

Are there any symptoms of thyroid disease? 

Long standing biochemical thyrotoxicosis, for example sub clinical disease with TSH suppression due to a multinodular goitre, increases the risk of osteoporosis.

Does the patient eat a varied diet with no food groups excluded? 

Patients taking restricted diets may be at increased risk of osteoporosis.

Are there any signs to suggest an eating disorder, or extreme weight loss of any cause? 

Anorexia and low body mass index are both risk factors for osteoporosis.

Does the patient take regular weight bearing exercise? 

Regular weight bearing exercise as well as normal or high body mass index are protective against osteoporosis.

Conversely, excessive exercise regimes may be associated with hypothalamic hypogonadism which may cause osteoporosis.

Does the patient expose their skin to sunshine? 

Complete coverage of the skin either with clothes or sunscreen may reduce vitamin D levels.

Is there any other medical history? 

Certain conditions, such as rheumatoid arthritis, chronic liver disease, inflammatory bowel disease and coeliac disease, are independent risk factors for osteoporosis.

What is the patient's full medication history? 

Patients on long term steroids (including via the trans dermal and inhaled routes) are at increased risk of osteoporosis, and should be treated during steroid therapy, irrespective of their bone mineral density.

Certain depot contraceptives may also lead to amenorrhoea and increased risk of osteoporosis.

Opiates, many psychotropic medications and other non prescribed drugs may also lead to hypogonadism, which is a risk factor for osteoporosis.

Anti retroviral drugs also increase the risk of osteoporosis.