Ejemplo Densitometria

Texto Libre :

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

json :

{
    "resourceType": "DiagnosticReport",
    "id": "http://example.org/fhir/StructureDefinition/DiagnosticReport-example-dxa",
    "text": {
        "status": "generated",
        --- We have skipped the narrative for better readability of the resource ---
    },
    "status": "final",
    "code": {
        "coding":  [
            {
                "system": "http://loinc.org",
                "code": "38269-7"
            }
        ],
        "text": "DXA BONE DENSITOMETRY"
    },
    "subject": {
        "reference": "Patient/pat2"
    },
    "effectiveDateTime": "2008-06-17",
    "issued": "06/17/2008 23:23:00",
    "performer":  [
        {
            "role": {
                "coding":  [
                    {
                        "system": "http://snomed.info/sct",
                        "code": "66862007",
                        "display": "Radiologist"
                    }
                ],
                "text": "Radiologist"
            },
            "actor": {
                "reference": "Practitioner/3ad0687e-f477-468c-afd5-fcc2bf897809",
                "display": "Dr Henry Seven"
            }
        }
    ],
    "result":  [
        {
            "reference": "Observation/bmd"
        }
    ],
    "codedDiagnosis":  [
        {
            "coding":  [
                {
                    "system": "http://snomed.info/sct",
                    "code": "391040000",
                    "display": "At risk of osteoporotic fracture"
                }
            ]
        }
    ]
}