colleen2282
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I have a provider questioning what is needed to meet independent interpretation. Patient was seen outside of our practice by unrelated office and but refers to the dexa scan ordered by outside provider, Clearly my provider has obtained and looked at the results and has come to a conclusion of his own and that patient is not receiving proper treatment at the other office. please let me know if you think the following documentation qualifies provider for a moderate in the risk category.
Reviewed prior documentation, labs, imaging
Based on prior DEXA scan, she is high risk for osteoporotic fracture (T score -2.7 right femoral neck, FRAX 23%/hip 8%). Reasonable to consider her high risk for fracture. However she is currently only on a conservative management plan through bone health institute. Recommend pt speak with them and tell them her PCP recommends pharm tx. Pt to regroup and let myself know if she would like to pursue tx if the bone institute declines addressing this further. Of note her fracture risk had increased from 2020 to 2021. Given high risk nature of her prior DEXA, can even consider referral to endo if she would like.
Right subscapularis likely strained, will refer to PT given chronicity and lack of improvement of sxs
Skin lesion - likely benign, pt to monitor if it changes in size/characteristics
Pt does do regular self breast exams s/p mastectomy 2/2 DCIS.
Reviewed prior documentation, labs, imaging
Based on prior DEXA scan, she is high risk for osteoporotic fracture (T score -2.7 right femoral neck, FRAX 23%/hip 8%). Reasonable to consider her high risk for fracture. However she is currently only on a conservative management plan through bone health institute. Recommend pt speak with them and tell them her PCP recommends pharm tx. Pt to regroup and let myself know if she would like to pursue tx if the bone institute declines addressing this further. Of note her fracture risk had increased from 2020 to 2021. Given high risk nature of her prior DEXA, can even consider referral to endo if she would like.
Right subscapularis likely strained, will refer to PT given chronicity and lack of improvement of sxs
Skin lesion - likely benign, pt to monitor if it changes in size/characteristics
Pt does do regular self breast exams s/p mastectomy 2/2 DCIS.