Diagnosticreport-example-dxa.xml

Imaging Example (Bone Density DXA) (id = "102")

<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="102"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
      <h2>DXA BONE DENSITOMETRY</h2>
      <table>
        <tr>
          <td>NAME</td>
          <td>XXXXXXX</td>
        </tr>
        <tr>
          <td>DOB</td>
          <td>10/02/1974</td>
        </tr>
        <tr>
          <td>REFERRING DR</td>
          <td>Smith, Jane</td>
        </tr>
        <tr>
          <td>INDICATIONS</td>
          <td>Early menopause on estrogen levels. No period  for 18 months</td>
        </tr>
        <tr>
          <td>PROCEDURE</td>
          <td>Dual energy x-ray absorptiometry (DEXA)</td>
        </tr>
      </table>
      <h3>Bone Mineral Density</h3>
      <table>
        <tr>
          <td>Scan Type</td>
          <td>Region</td>
          <td>Measured</td>
          <td>Age</td>
          <td>BMD</td>
          <td>T-Score</td>
          <td>Z-Score</td>
          <td>?BMD(g/cm2)</td>
          <td>?BMD(%)</td>
        </tr>
        <tr>
          <td>AP Spine</td>
          <td>L1-L4</td>
          <td>17/06/2008</td>
          <td>34.4</td>
          <td>1.148 g/cm²</td>
          <td>-0.4</td>
          <td>-0.5</td>
          <td>-</td>
          <td>-</td>
        </tr>
        <tr>
          <td>Left Femur</td>
          <td>Neck</td>
          <td>17/06/2008</td>
          <td>34.4</td>
          <td>0.891 g/cm²</td>
          <td>-1.0</td>
          <td>-0.9</td>
          <td>-</td>
          <td>-</td>
        </tr>
        <tr>
          <td>Left Femur</td>
          <td>Total</td>
          <td>17/06/2008</td>
          <td>34.4</td>
          <td>0.887 g/cm²</td>
          <td>-1.2</td>
          <td>-1.3</td>
          <td>-</td>
          <td>-</td>
        </tr>
        <tr>
          <td>Right Femur</td>
          <td>Neck</td>
          <td>17/06/2008</td>
          <td>34.4</td>
          <td>0.885 g/cm²</td>
          <td>-1.0</td>
          <td>-1.0</td>
          <td>-</td>
          <td>-</td>
        </tr>
        <tr>
          <td>Right Femur</td>
          <td>Total</td>
          <td>17/06/2008</td>
          <td>34.4</td>
          <td>0.867 g/cm²</td>
          <td>-1.4</td>
          <td>-1.4</td>
          <td>-</td>
          <td>-</td>
        </tr>
      </table>
      <p>Assessment:</p>
      <ul>
        <li>The Spine L1-L4 BMD is normal.</li>
        <li>The Left Femur Neck BMD is in the osteopenic range. Relative fracture risk is about 2.</li>
        <li>The Left Femur Total BMD is in the osteopenic range. Relative fracture risk is about 2.</li>
        <li>The Right Femur Neck BMD is in the osteopenic range. Relative fracture risk is about 2.</li>
        <li>The Right Femur Total BMD is in the osteopenic range. Relative fracture risk is about
           2.</li>
      </ul>
      <p>
        <b>COMMENT</b>
      </p>
      <p>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.</p>
      <p>Thank you for your referral.  Dr Peter Ng  17/06/2008</p>
      <pre>
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
</pre>
    </div>
  </text>
  <status value="final"/>
  <!--        femur, laterality = left        -->
  <!--        first, various administrative/context stuff        -->
  <code>
    <coding>
      <system value="http://loinc.org"/>
      <code value="38269-7"/>
    </coding>
    <text value="DXA BONE DENSITOMETRY"/>
  </code>
  <subject>
    <reference value="Patient/pat2"/>
  </subject>
  <effectiveDateTime value="2008-06-17"/>
  <!--        all this report is final        -->
  <issued value="2008-06-18T09:23:00+10:00"/>
  <!--        well, actually. this isn't the patient, but it'll do for now        -->
  <performer>
    <reference value="Organization/1832473e-2fe0-452d-abe9-3cdb9879522f"/>
    <display value="Acme Imaging Diagnostics"/>
  </performer>
  <result>
    <reference value="Observation/bmd"/>
<!--     but just one for now,  but for this example there should be more as listed here 
<reference value="Observation/bmd1"/>      (LEFT  24701-5  Femur DXA Bone densityO g/cm2)
     
<reference value="Observation/bmd2>      (LEFT 8263-0  Femur DXA [T-score] Bone densityO
     {T-score})

<reference value="Observation/bmd3"/>      (RIGHT 24701-5  Femur DXA Bone densityO g/cm2)
<reference value="Observation/bmd4"/>      (RIGHT 38263-0  Femur DXA [T-score] Bone densityO
     {T-score})

<reference value="Observation/bmd5"/>      (24966-4  Lumbar spine DXA Bone densityO g/cm2)
<reference value="Observation/bmd6"/>     (38267-1  Lumbar spine DXA [T-score] Bone densityO
     {T-score})
  -->  </result>
  <!--        the imaging service marks this to help find categories of patient        -->
  <codedDiagnosis>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="391040000"/>
      <display value="At risk of osteoporotic fracture"/>
    </coding>
  </codedDiagnosis>
</DiagnosticReport>