R5 Final QA

This page is part of the FHIR Specification (v5.0.0-draft-final: Final QA Preview for R5 - see ballot notes). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Example DiagnosticReport/102 (Narrative)

Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner

This is the narrative for the resource. See also the XML, JSON or Turtle format. This example conforms to the profile DiagnosticReport.

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.