Diagnosticreport-example-dxa

Orders and Observations Work Group

Maturity Level: N/A

Standards Status: Informative

Compartments: Device, Encounter, Patient, Practitioner

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DXA BONE DENSITOMETRY

NAME	XXXXXXX
DOB	10/02/1974
REFERRING DR	Smith, Jane
INDICATIONS	Early menopause on estrogen levels. No period for 18 months
PROCEDURE	Dual energy x-ray absorptiometry (DEXA)

Bone Mineral Density

Scan Type	Region	Measured	Age	BMD	T-Score	Z-Score	?BMD(g/cm2)	?BMD(%)
AP Spine	L1-L4	17/06/2008	34.4	1.148 g/cm²	-0.4	-0.5	-	-
Left Femur	Neck	17/06/2008	34.4	0.891 g/cm²	-1.0	-0.9	-	-
Left Femur	Total	17/06/2008	34.4	0.887 g/cm²	-1.2	-1.3	-	-
Right Femur	Neck	17/06/2008	34.4	0.885 g/cm²	-1.0	-1.0	-	-
Right Femur	Total	17/06/2008	34.4	0.867 g/cm²	-1.4	-1.4	-	-

Assessment:

The Spine L1-L4 BMD is normal.
The Left Femur Neck BMD is in the osteopenic range. Relative fracture risk is about 2.
The Left Femur Total BMD is in the osteopenic range. Relative fracture risk is about 2.
The Right Femur Neck BMD is in the osteopenic range. Relative fracture risk is about 2.
The Right Femur Total BMD is in the osteopenic range. Relative fracture risk is about 2.

COMMENT

Osteopenia on measured BMD. The estimated 10-year probability of fracture based on present age, gender and measured BMD is less than 10%. This absolute fracture risk remains low. A follow-up assessment may be considered in 2 to 3 years to monitor the trend in BMD.

Thank you for your referral. Dr Henry Seven 17/06/2008

Note:
WHO classification of osteoporosis (WHO Technical Report Series 1994: 843)
- Normal: T-score equal to -1.0 s.d. or higher
- Osteopenia: T-score  between -1.0 and -2.5 s.d.
- Osteoporosis: T-score equal to -2.5 s.d. or lower
- Severe/Established osteoporosis: Osteoporosis with one or more fragility fracture.
T-score: The number of s.d. from the mean BMD for a gender-matched young adult population.
Z-score: The number of s.d. from the mean BMD for an age-, weight- and gender-matched population.
Reference for 10-year probability of fracture risk: Kanis JA, Johnell O, Oden A, Dawson A,  De Laet C, Jonsson B. Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds. Osteoporos.Int. 2001;12(12):989-995.
GE LUNAR PRODIGY DENSITOMETER

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.