International Patient Summary Implementation Guide
2.0.0-ballot - STU 2 Ballot International flag

This page is part of the International Patient Summary Implementation Guide (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

Example Observation: Observation: imaging CT Abdomen W contrast IV, sub-observations

Page standards status: Informative

Generated Narrative: Observation ips-example-imaging-4

partOf: ImagingStudy: identifier = urn:dicom:uid#DICOM Unique Id#urn:oid:2.16.840.1.113883.2.9.999.1.12345; status = available; procedureCode = SPECT Heart perfusion and wall motion at rest and W stress and W Tl-201 IV and W Tc-99m Sestamibi IV; reasonCode =

status: Final

category: Imaging

code: Upper abdomen with the administration of oral and intravenous contrast (example-4)

subject: Alexander Heig Male, DoB: 1957 ( http://trilliumbridge.eu/fhir/demos/eumfh/inject#39-07)

effective: 1995-06-08

performer:

value: 3 cm nodule present in the inferior medial aspect of right liver lobe. Contrast enhancement pattern consistent with the diagnosis of hemangioma.

component

code: Procedure Description

value: Serial imaging was obtained in the upper abdomen with the administration of oral and intravenous contrast.

component

code: Finding

value: The examination demonstrates a well circumscribed 3 cm lesion present within the medial aspect of the inferior right liver lobe. Initial evaluation demonstrates lack of contrast enhancement. Subsequent imaging (not shown) demonstrated typical contrast enhancement pattern of a benign hemangioma of the liver. The remaining contrast enhancement pattern in the liver is normal. There is normal appearance of the adrenal glands, spleen, kidneys, and pancreas. There is no evidence of liver metastasis.