Diagnosticreport-example-dxa.xml

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

Raw XML

<DiagnosticReport xmlns="http://hl7.org/fhir">
  <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>ΔBMD(g/cm2)</td>
          <td>ΔBMD(%)</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>
  <contained>
    <!--   Here is one of the measurements above encoded as an observation for example purposes.
       -->
    <Observation id="r1">
      <name>
        <coding>
          <system value="http://loinc.org"/>
          <code value="24701-5"/>
          <display value="Femur DXA Bone density"/>
        </coding>
      </name> 
      <valueQuantity>
        <value value="0.887"/>
        <units value="g/cm²"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="g/cm-2"/>
      </valueQuantity>
      <status value="final"/>
      <reliability value="ok"/>
      <bodySite>
        <coding>
          <system value="http://snomed.info/sct"/>
          <code value="71341001:272741003=7771000"/> <!--   femur, laterality = left   -->
        </coding>
      </bodySite>
    </Observation>
  </contained> 

  
<!--   first, various administrative/context stuff   -->
  <name>
    <coding>
      <system value="http://loinc.org"/>
      <code value="38269-7"/>
    </coding>
    <text value="DXA BONE DENSITOMETRY"/>
  </name>
  <status value="final"/> <!--   all this report is final   -->
  <issued value="2008-06-18T09:23:00+10:00"/>
  <subject>
    <reference value="Patient/pat2"/> <!--   well, actually. this isn't the patient, but it'll do for now   -->
  </subject>
  <performer>
    <reference value="Organization/1832473e-2fe0-452d-abe9-3cdb9879522f"/>
    <display value="Acme Imaging Diagnostics"/>
  </performer>
  <diagnosticDateTime value="2008-06-17"/>
  <result>
    <reference value="#r1"/>
  </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>  
  <!--   actually, of course, this is a wrong code - since the risk is &lt;10%, it wouldn't be
   characterised as at risk. To do: fix this?   -->  
    
</DiagnosticReport>