Patients come to my clinic or are referred here because they have low bone density or osteoporosis or are concerned they do and want confirmation. Some want a second opinion regarding their treatment options. We evaluate them. When the DXA test shows a T score of less than –2 at the spine or hip that is low bone density and if the T score is less than –2.5 at the spine or hip that is osteoporosis. A number of diseases present with low bone density with osteoporosis being the most common but a common error in diagnostic medicine is to accept the most frequent cause of a condition as its diagnosis without looking further to confirm it.
Osteomalacia, multiple myeloma, Cushing disease and primary hyperparathyroidism all cause osteoporosis and can present with low bone density and/or osteoporosis. Some of these will even respond to standard treatment for osteoporosis but the responses will the poor at best and disastrous at worse. When the diagnosis and treatment of these people based on the patient’s history, physical exam, and abnormal DXA alone, the diagnosis has not been confirmed in the laboratory. In this case, if the practitioner has diagnosed “typical” Postmenopausal Osteoporosis, PMO in white women and will be correct the majority of the time. Testing should still be done even when there is little doubt in anyone’s mind regarding the validity of the diagnosis because studies show 20% of the time there will be another cause for bone loss in addition to PMO present. The basic laboratory evaluation I use is designed to efficiently and cost effectively excludes the most common and likely secondary causes of osteoporosis.
All osteoporosis consultations conducted here begin with a thorough review of the patient’s medical and surgical history, their medication use, their family history and use of alcohol and tobacco. Diet and exercise practices are very important to understand and if needed help the patient optimize for them to get the greatest benefit from treatment
A complete physical exam is performed to look for signs of medical causes of osteoporosis and to best assess the patient’s medical health and fitness. The exam should be disease specific with special attention to the spine, joints, patient’s mobility, exercise potential, balance and fall risk. After DXA, history, and physical are complete a diagnosis is rendered and a laboratory evaluation is planned. The patient is referred to the lab for basic osteoporosis laboratory evaluation. They are placed on a preliminary treatment based on the results available. This might include recommendations for diet, exercise, and supplements. Drug therapy might be recommended at that time of withheld until the results of the evaluation are complete. Our practice is to give the patient a follow up appointment to discuss their lab work and if placed on medication for osteoporosis to see how they are doing on it. After the patient is given their appointment usually for 1 month, that ends the visit and the first part of the evaluation. Over the next week or two, the lab results will come in and be reviewed, when the patient returns to the office to go over her results we are ready to discuss them and discuss together what to do next. This concludes the initial evaluation.