Geriatric SOAP Note about GOUT Disease

Geriatric SOAP Note

Osteopenia

Demographics

Name: C.S.

Age: 65

Sex: Female

Race: White

Chief Complaint (Reason for seeking health care)

"I’m here because my doctor told me I have osteopenia, and I want to know what I can do to stop it from getting worse."

History of Present Illness (HPI)

C.S. is a 65-year-old White female who presents for follow-up after being diagnosed with osteopenia following a routine DEXA scan performed three months ago. She reports no specific bone pain but states she occasionally experiences mild lower back discomfort, especially after prolonged standing or walking, which began about six months ago (onset). The discomfort is located in the lower lumbar region (location) and is intermittent in nature (duration). She describes the sensation as a dull ache (character) that worsens with physical exertion or standing for long periods (aggravating factors) and improves with rest and sitting (relieving factors). The discomfort tends to occur more frequently in the evenings after an active day (timing) and rates it as a 3 out of 10 in severity. She denies any history of falls, fractures, or use of corticosteroids, but reports limited weight-bearing exercise and a diet low in calcium and vitamin D prior to diagnosis.

Allergies

Review of Systems (ROS)

General: PT admits to mild fatigue for many months but denies weight loss or fever. She feels well except sometimes from back trouble. PT denies feeling cold at night.

HEENT: PT denies hearing loss, vision issues, and headaches. Though she denies nasal congestion and sore throat, dry eyes can sometimes strike. No dental problems.

Neck: The PT denies any neck discomfort. She rotates and sometimes has minor headaches; there is no bumps or swelling. Never suffered with thyroid problems.

Lungs: PT denies coughing, wheezing, and dyspnea. She has little exertional dyspnea on her way there. absent respiratory disease or asthma.

Cardio: PT denies chest pain, palpitations, and edema. She becomes lightheaded but not faint from standing quickly. Never suffered from heart disease or hypertension.

Breast: PT denies lumps, pain, and drainage from the breast. She claims she routinely and without trouble self-examines. No current mammograms or breast problems.

Gastrointestinal: PT denies gastrointestinal problems, nausea, vomiting, and stomach pain. Her constipation is different. Never had ulcers or GI bleeding.

Male/Female Genital: PT denies vaginal discharge or bleeding at the menopause in both sexes. Heat waves in menopause. Pelvic pain-free and infection-free.

Genitourinary: PT denies urgency, dysuria, and frequency in the Genitourinary system. Little urine incontinence occurs after coughing and sneezing. No urinary tract infections.

Neurological: PT denies numbness, dizziness, and headaches. She isn't weak or shaking; she's forgetful. Never had a stroke or seizure.

Musculoskeletal: Although PT denies joint swelling or muscle weakening, PT admits minor lower back pain associated with osteopenia. Denials of recent fractures or trauma. No stated motion restrictions.

Activity: PT admits reducing physical activity to reduce bone damage but disputes inactivity. Every day she walks little distances. Without help.

Psychosocial: PT denies sadness but is concerned about bones. Her family and friends help her. Never abused narcotics.

Derm: PT denies rashes, itching, and skin changes. She has dry winter skin. Free of lesions or skin illnesses.

Nutrition: PT admits to a diet lacking in calcium and vitamin D before to diagnosis but has started taking supplements. Denounced are recent changes in hunger. Neither swallowing nor digesting problems.

Sleep/Rest: PT denies being sleepy but acknowledges that back discomfort disturbs sleep. Every night she sleeps six or seven hours. Free of sleep aids.

Last Menstrual Period (LMP):PT began menopause twelve years ago with last menstrual period (LMP). She claims not to have postmenopausal bleeding. Not now using any hormones replacement.

STI History: PT denies any STIs in her past. She comes clean about years of non-activity sexually. No any current tests or problems.

Vital Signs

Blood pressure: 132/78 mmHg

Heart rate: steady rhythm, 78 beats per minute

16 unforced breaths per minute is the respiratory rate.

Oral temperature: 98.4°F

150 lbs (68 kg) in weight

5 feet 4 inches (163 cm) tall

25.8 kg/m² is the body mass index (BMI) for overweight people.

Pain: 3/10, little soreness in the lower back

Labs

Recent DEXA scan: T-score of -1.8 at the lumbar spine (consistent with osteopenia)

Serum calcium: 9.2 mg/dL (normal)

Vitamin D (25-OH): 22 ng/mL (low)

Serum phosphorus: 3.5 mg/dL (normal)

Complete blood count (CBC): Within normal limits

Medications

Calcium carbonate 600 mg, oral, twice daily — for osteopenia and calcium supplementation

Vitamin D3 1,000 IU, oral, daily — for vitamin D deficiency and bone health

Acetaminophen 500 mg, oral, as needed for mild back discomfort

Past Medical History

Osteopenia, diagnosed 2024, active

Hypertension, diagnosed 2018, well-controlled, active

Seasonal allergies, diagnosed 2005, intermittent, active

Appendectomy, 1990, resolved

No history of fractures or major trauma

No prior hospitalizations in the past 5 years

Past Surgical History

Appendectomy, 1990 — treatment of acute appendicitis

Cataract surgery, 2015 — age-related cataracts

Total hysterectomy, 2008 — uterine fibroids

Family History

Mother: Diagnosed in her 70s with osteoporosis and type 2 diabetes, she is still living today.

Father: died of a myocardial infarction at the age of 75 due to coronary artery disease.

Sister: At age 55, she had a breast cancer diagnosis that is now in remission.

Brother: In good health, with no known hereditary conditions or chronic diseases

Social History

Tobacco usage: Refuses to acknowledge previous or present tobacco use

Alcohol consumption: 1-2 glasses of wine per week, sometimes with meals

Drug use: denies using illegal or recreational drugs.

Status of marriage: widowed

Work status: retired, with prior experience as a school librarian

Sexual orientation: not sexually active at the moment; heterosexual

Use of contraception: Not relevant (post-menopausal)

Life situation: Independent in daily life activities, living alone in a single-family residence

Health Maintenance/ Screenings

Mammogram: normal, completed in 2023

Normal colonoscopy completed in 2020; next expected in 2030

Osteopenia is shown by a 2024 DEXA scan (T-score -1.8).

Pap smear: Not relevant (for benign conditions after a hysterectomy)

Lipid panel: finished in 2023; LDL is rather increased

Immunizations:

Influenza: Current, latest reported in the autumn of 2024

COVID-19: Completely immunized with a 2024 booster

Tdap: 2021 last dosage

Pneumococcal: PCV13 and PPSV23 were given to me; finished the two-dose course in 2023.

Physical Examination

General:

PT is focused and attentive x3.

Healthy diet, and lack of severe discomfort

Stable but careful gait

Vital signs are steady and within typical ranges.

HEENT:

Normal and atraumatic head

Pupils are round, equal, and responsive to light and adaptation (PERRLA).

No lesions or dental problems were seen, and the oral mucosa was moist.

Clear tympanic membranes devoid of infection

Neck:

Full range of motion and suppleness

Absence of lymphadenopathy

No palpable thyroid nodules or enlargement

Carotid bruits were not seen.

Lungs:

Both sides are clear during auscultation.

No wheezes, rhonchi, or rales

Symmetric enlargement of the chest

There was no evidence of auxiliary muscle use.

Cardio:

Consistent rhythm and pace

No gallops, no rubs, no moans

Absence of JVD (jugular vein distention)

Bilateral peripheral pulses 2+

Breast:

No discomfort or palpable lumps were seen.

No retraction or discharge of the nipples

Breast skin is unbroken and free of erythema.

No lymphadenopathy in the axilla

Gastrointestinal:

Soft, non-tender, and not enlarged abdomen

Every region has bowel noises.

Hepatosplenomegaly is absent.

No discernible masses

Male/Female Genital:

External genitalia in both males and females that are free of lumps or lesions

No vaginal discharge was seen.

No indications of inflammation or atrophy

Due to a history of complete hysterectomy, the pelvic exam was postponed.

Genitourinary:

No soreness above the pubic region

No soreness at the costovertebral angle (CVA)

Absence of bladder distention

Reports having minor stress incontinence; there is no urgency or test frequency.

Neurologic:

The second to XII cranial nerves are mostly intact.

Strength 5/5 in the lower and upper limbs

Intact sensitivity to vibration and light touch

Bilateral deep tendon reflexes of 2+

Musculoskeletal:

Lower lumbar spine probing revealed mild pain; no joint swelling or abnormalities were seen.

All extremities' full range of motion

There was no evidence of muscular atrophy.

Activity:

Walks steadily and independently

shows hesitancy when getting out of a chair, doesn't utilize any assistive technology, and reports being less active because of worries about bone health.

Psychosocial:

Proper emotion and mood

denies having anxiety or sadness

Good understanding of the state of health

solid support network and consistent family contact

Derm:

No rashes, skin is dry and warm.

There is some xerosis on the lower limbs.

No bruises or open lesions

Hair and nails that seem healthy

Diagnosis

Osteopenia – ICD-10 Code: M85.80 (Other specified disorders of bone density and structure, unspecified site)

Osteopenia is a condition characterized by lower-than-normal bone mineral density (BMD), but not low enough to be classified as osteoporosis. It indicates a reduction in bone mass that increases the risk for fractures. The principal diagnosis of osteopenia is supported by the patient’s DEXA scan results showing a T-score of -1.8 at the lumbar spine, which falls within the range for osteopenia (T-score between -1.0 and -2.5) (Varacallo et al., 2023). The patient reports mild lower back discomfort and reduced physical activity due to concerns about bone fragility. Her age (65 years), postmenopausal status, and decreased vitamin D levels are contributing risk factors that support this diagnosis. Early identification and management are essential to prevent progression to osteoporosis and reduce fracture risk.

Differential Diagnosis

Osteoporosis (ICD-10: M81.0)

The gradual systemic skeletal illness osteoporosis causes low bone mass and microarchitectural bone tissue degeneration, making bones more fragile and prone to fractures (Adami et al., 2022). Osteoporosis is important to distinguish from osteopenia since it shares several risk factors, including advanced age, female sex, postmenopause, and vitamin D insufficiency. The patient's DEXA scan T-score of -1.8 does not satisfy the diagnostic criterion for osteoporosis (T-score < -2.5), ruling out this disease. The patient also denies fragility fractures and acute bone pain, which would indicate extensive bone loss.

ICD-10 Code: M83.9 Osteomalacia

Bone softening owing to improper mineralization is usually induced by vitamin D insufficiency or phosphate depletion in adults (Zimmerman & McKeon, 2020). Osteomalacia may resemble osteopenia radiographically and cause bone pain and muscular weakness. It was considered since the patient's blood vitamin D level (22 ng/mL) is below the bone health criterion. The patient does not have generalized bone pain, proximal muscle weakness, or trouble walking, ruling out the diagnosis. Serum calcium, phosphate, and alkaline phosphatase are normal, reducing osteomalacia risk.

ICD-10 Code: C90.00 Multiple Myeloma

Plasma cell growth in the bone marrow causes bone pain, anemia, and lytic bone lesions in multiple myeloma (Albagoush et al., 2023). This diagnosis applies to elderly persons with unexplained bone density decrease or back discomfort. This patient has no red flag signs like weight loss, exhaustion, anemia, hypercalcemia, or pathological fractures, ruling it out. No systemic disease, many lytic bone lesions, or abnormal complete blood count, calcium, or renal function were seen.

ICD 10 Coding

ICD-10 Code: M81.0

ICD-10 Code: M83.9

ICD-10 Code: C90.00

Pharmacologic treatment plan

Calcium carbonate 600 mg with vitamin D (cholecalciferol 800 IU)

Route: Oral

Frequency: Twice daily with meals

Duration: Ongoing (lifelong supplementation recommended)

Cost: Approx. $10–15/month (OTC)

Education: Take with food to improve absorption; avoid taking with iron supplements or high-fiber meals for optimal efficacy. Essential to support bone mineralization and reduce bone loss risk (Shi et al., 2025).

Alendronate 70 mg

Route: Oral

Frequency: Once weekly

Duration: Reassess at 3–5 years based on repeat DEXA scan

Cost: Generic approx. $20–30/month

Education: Take first thing in the morning with 8 oz of water, at least 30 minutes before eating, drinking, or taking other meds; remain upright for 30 minutes after dosing to prevent esophageal irritation (Parker & Preuss, 2023). Used off-label in osteopenia with T-score < -1.5 and fracture risk.

Continue current vitamin D3 2000 IU/day

Route: Oral

Frequency: Daily

Duration: Ongoing

Cost: Approx. $5–10/month (OTC)

Education: Maintains serum 25(OH)D levels above 30 ng/mL to support calcium absorption (Grant et al., 2025).

Diagnostic/Lab Testing

DEXA scan: Already completed, T-score -1.8 (osteopenia range)

Vitamin D (25-OH): 22 ng/mL (low)

Serum Calcium and Phosphorus: Normal

Education

Encourage weight-bearing exercises (walking, light resistance training) 3–4 times/week to strengthen bones.

Advise adequate calcium and vitamin D intake through diet and supplements.

Discuss fall prevention strategies at home (remove tripping hazards, use handrails).

Self-Management:

Keep a daily log of medication and supplement intake to ensure adherence.

Maintain a balanced diet rich in leafy greens, dairy, and fortified foods.

Practice safe movement and posture techniques to reduce fracture risk.

Anticipatory Guidance

Primary Prevention:

Encourage lifelong calcium and vitamin D intake to maintain bone health (Shi et al., 2025).

Promote regular weight-bearing and muscle-strengthening exercises to prevent bone loss (Papadopoulou et al., 2021).

Advise smoking cessation and limiting alcohol intake to reduce osteoporosis risk (LeBoff et al., 2022).

Secondary Prevention:

Schedule repeat DEXA scans every 2 years to monitor bone density (Riemer et al., 2024).

Conduct fall risk assessments annually to prevent fractures.

Follow up plan

Follow up in 6 months to assess symptom progression and adherence to treatment.

Repeat DEXA scan in 2 years to monitor bone density.

Prescription

See Below (scroll down)

References

Grammar

EA#: 999999999 STU Clinic LIC# 7878787878

Tel: (786) 323-7878 FAX: (786) 222-0000

Patient Name: (Initials)_____C.S_________________________ Age ___65________

Date: _06/01/2025______________

RX ___Alendronate 70 mg tablet___________________________________

SIG: Take one tablet orally once weekly in the morning with 8 oz of water; remain upright for 30 minutes after taking.

Dispense: ___4 tablets________ Refill: _2________________

No Substitution

Signature:__Alexsandra P. Lima APRN