A question before I answer
#1. Is this the first time this provider has seen this pt
From the way you stated it seems to me like the doc is sending pt back to pcp for management.
If this is the case, it would be new problem to examiner, no additional work-up would be 3 points.
If this is not the first time this provider has seen the pt, then since it's a recurring problem I'd give it established problem worsening...
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Roxanne Thames, CPC
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