International Patient Summary Implementation Guide
1.0.0 - STU 1

This page is part of the International Patient Summary Implementation Guide (v1.0.0: STU 1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

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

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<Observation xmlns="http://hl7.org/fhir">
<!--  TRILLIUM II Project
		Example of imaging observation including the information of example 2 (some essential and contextual data ) plus:
	- reason For Study (example 3)
	- target region (example 3)
	- acquisition device (example 3)
	- list of evidence references (example 3)
	- reference to the report 

	Only textual results including overall result and findings
     -->
  <id value="trilliumII-example-imaging-4"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
			<p>
				<b>date</b>: 1995-06-08
            </p>
			<p>
				<b>subject</b>: <a>Patient/eumfh-39-07</a>
			</p>
			<p>
				<b>CT Abdomen W contrast IV</b>
			</p>
			<p>
				<b>Procedure Description:</b>Serial imaging was obtained in the upper abdomen with the administration of oral and intravenous contrast.</p>
			<p>
				<b>Finding:</b>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.</p>
			<p>
				<b>Conclusion:</b>3 cm nodule present in the inferior medial aspect of right liver lobe. Contrast enhancement pattern consistent with the diagnosis of hemangioma.
            </p>
		</div>
  </text>
  <partOf>
    <reference value="ImagingStudy/TII-ImagingStudy-5-1"/>
  </partOf>
  <status value="final"/>
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/observation-category"/>
      <code value="imaging"/>
      <display value="Imaging"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://loinc.org"/>
      <code value="79103-8"/>
      <display value="CT Abdomen W contrast IV"/>
    </coding>
    <text
          value="Upper abdomen with the administration of oral and intravenous contrast (example-4)"/>
  </code>
<!--  in the profile effectiveTime is 0...1 so it can be omitted  -->
  <subject>
    <reference value="Patient/eumfh-39-07"/>
  </subject>
  <effectiveDateTime value="1995-06-08"/>
  <performer>
    <reference value="Practitioner/eumfh-39-07"/>
  </performer>
  <performer>
    <reference value="Organization/TII-Organization1"/>
  </performer>
  <valueString
               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>
      <coding>
        <system value="http://dicom.nema.org/resources/ontology/DCM"/>
        <code value="121065"/>
        <display value="Procedure Description"/>
      </coding>
    </code>
    <valueString
                 value="Serial imaging was obtained in the upper abdomen with the administration of oral and intravenous contrast."/>
  </component>
  <component>
    <code>
      <coding>
        <system value="http://dicom.nema.org/resources/ontology/DCM"/>
        <code value="121071"/>
        <display value="Finding"/>
      </coding>
    </code>
    <valueString
                 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."/>
  </component>
</Observation>