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id: e39e8417-ceb2-4e24-941f-2166e1a0e9b1 (excluded)
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DiagnosticReport/1/_history/1 Modified: 5/28/2019 2:45:12 PM +02:00

HLA-A,-B,-C genotyping report for Mary Chalmers (MRN:12345)

  LOCUS   ALLELE 1            ALLELE 2
  HLA-A   HLA-A:01:01G        HLA-A*01:02
  HLA-B   HLA-B*15:01:01G     HLA-B*57:01:01G
  HLA-C   HLA-C*01:02:01G     HLA-C*03:04:01G
                

Allele assignments based on IMGT/HLA 3.23

Effective date: 2015-12-15

Method: Sequencing of exons 2 and 3 of HLA Class I genes

Lab: aTypingLab Inc

Note: Please refer the implementation guide for more explanation on this carefully organized bundle example.

  Bob Milius - NMDP - 2016-12-01

  Transaction bundle that creates and links:
  + DiagnosticReport summarizing genotyping for HLA-A,-B,-C typing of patient(donor)
  + Obervations for each genotype
  + Observations for each allele
  + Sequences for exons 2 and 3 for HLA-A,-B, -C

  The endpoints of the following resources are hardcoded into this transaction bundle
  because these are presumed to already exist when developing the DiagnosticRequest
  which was to generate this report bundle:

  Patient/119 (potential donor)
  Specimen/120 (buccal swab)
  Organization/68  (typing lab)
  ServiceRequest/123  (report is based on this request)
                
DiagnosticReport/101/_history/1 Modified: 5/28/2019 2:45:01 PM +02:00

CBC Report for Wile. E. COYOTE (MRN: 23453) issued 3-Mar 2011 11:45

Test                  Units       Value       Reference Range
Haemoglobin           g/L         176         135 - 180
Red Cell Count        x10*12/L    5.9         4.2 - 6.0
Haematocrit                       0.55+       0.38 - 0.52
Mean Cell Volume      fL          99+         80 - 98
Mean Cell Haemoglobin pg          36+         27 - 35
Platelet Count        x10*9/L     444         150 - 450
White Cell Count      x10*9/L     4.6         4.0 - 11.0
Neutrophils           %           20
Neutrophils           x10*9/L     0.9---      2.0 - 7.5
Lymphocytes           %           20
Lymphocytes           x10*9/L     0.9-        1.1 - 4.0
Monocytes             %           20
Monocytes             x10*9/L     0.9         0.2 - 1.0
Eosinophils           %           20
Eosinophils           x10*9/L     0.92++      0.04 - 0.40
Basophils             %           20
Basophils             x10*9/L     0.92+++     <0.21
      

Acme Laboratory, Inc signed: Dr Pete Pathologist

DiagnosticReport/102/_history/1 Modified: 5/28/2019 2:45:02 PM +02:00

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:

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
DiagnosticReport/dg2/_history/1 Modified: 5/28/2019 2:45:12 PM +02:00

Genetic test Report for Marry Chalmers (MRN: 12345)

              Gene                DNAVariation       Status        Interpretation
              BRCA1                                 Negative
              BRCA2                 185delAG        Positive         Pathogenic
          

Method: BRACAnalysis CDx Offered by Myriad Genetic Laboratories, Inc

Issued: 2015-05-26T15:30:10+01:00

FamilyMemeberHistory: Mother

              Gene                 DNAVariation      Status
              BRCA2                 185delAG        Positive
          

Method: BRACAnalysis CDx Offered by Myriad Genetic Laboratories, Inc

DiagnosticReport/example-pgx/_history/1 Modified: 5/28/2019 2:45:07 PM +02:00

Generated Narrative with Details

id: example-pgx

basedOn: ServiceRequest/example-pgx

status: final

code: Pharmacogenetics Report (Details : {https://system/PGxReport code 'PGxReport' = 'PGxReport', given as 'Pharmacogenetics Report'})

subject: Bob Smith

effective: 15/10/2016 12:34:56 PM

issued: 20/10/2016 2:00:05 PM

performer: Organization/4829

result: Observation/example-phenotype

presentedForm:

DiagnosticReport/f001/_history/1 Modified: 5/28/2019 2:45:02 PM +02:00

Generated Narrative with Details

id: f001

identifier: nr1239044 (OFFICIAL)

basedOn: ServiceRequest/req

status: final

category: Haematology test (Details : {SNOMED CT code '252275004' = 'Haematology test', given as 'Haematology test'}; {http://terminology.hl7.org/CodeSystem/v2-0074 code 'HM' = 'Hematology)

code: Complete blood count (hemogram) panel - Blood by Automated count (Details : {LOINC code '58410-2' = 'Complete blood count (hemogram) panel - Blood by Automated count', given as 'Complete blood count (hemogram) panel - Blood by Automated count'})

subject: P. van den Heuvel

issued: 15/05/2013 7:32:52 PM

performer: Burgers University Medical Centre

result:

conclusion: Core lab

DiagnosticReport/f201/_history/1 Modified: 5/28/2019 2:45:02 PM +02:00

Generated Narrative with Details

id: f201

status: final

category: Radiology (Details : {SNOMED CT code '394914008' = 'Radiology - speciality', given as 'Radiology'}; {http://terminology.hl7.org/CodeSystem/v2-0074 code 'RAD' = 'Radiology)

code: CT of head-neck (Details : {SNOMED CT code '429858000' = 'Computed tomography (CT) of head and neck', given as 'Computed tomography (CT) of head and neck'})

subject: Roel

effective: 01/12/2012 12:00:00 PM

issued: 01/12/2012 12:00:00 PM

performer: Blijdorp MC

imagingStudy: HEAD and NECK CT DICOM imaging study

conclusion: CT brains: large tumor sphenoid/clivus.

conclusionCode: Malignant tumor of craniopharyngeal duct (Details : {SNOMED CT code '188340000' = 'Malignant tumor of craniopharyngeal duct', given as 'Malignant tumor of craniopharyngeal duct'})

DiagnosticReport/f202/_history/1 Modified: 5/28/2019 2:45:02 PM +02:00

Generated Narrative with Details

id: f202

basedOn: ServiceRequest/req

status: final

category: Laboratory test (Details : {SNOMED CT code '15220000' = 'Laboratory test', given as 'Laboratory test'}; {http://terminology.hl7.org/CodeSystem/v2-0074 code 'LAB' = 'Laboratory)

code: Blood culture for bacteria, including anaerobic screen (Details : {SNOMED CT code '104177005' = 'Blood culture for bacteria, including anaerobic screen', given as 'Blood culture for bacteria, including anaerobic screen'})

subject: Roel

issued: 11/03/2013 10:28:00 AM

performer: AUMC

result: Results for staphylococcus analysis on Roel's blood culture

conclusion: Blood culture tested positive on staphylococcus aureus

conclusionCode: Bacteremia due to staphylococcus (Details : {SNOMED CT code '428763004' = 'Bacteremia due to Staphylococcus aureus', given as 'Bacteremia due to staphylococcus'})

DiagnosticReport/ghp/_history/1 Modified: 5/28/2019 2:45:02 PM +02:00

Generated Narrative with Details

id: ghp

meta:

identifier: ghp-example

status: final

code: General Health Profile (Details : {http://acme.com/labs/reports code 'GHP' = 'GHP', given as 'General Health Profile'})

subject: Patient/pat2

effective: 16/08/2015 6:40:17 AM

issued: 17/08/2015 6:40:17 AM

performer: Acme Laboratory, Inc

specimen:

result:

DiagnosticReport/gingival-mass/_history/1 Modified: 5/28/2019 2:45:05 PM +02:00

Generated Narrative with Details

id: gingival-mass

identifier: P73456090

status: final

category: Pathology (Details : {http://terminology.hl7.org/CodeSystem/v2-0074 code 'PAT' = 'Pathology (gross & histopath, not surgical)', given as 'Pathology (gross & histopath, not surgical)'})

code: Biopsy without Microscopic Description (1 Site/Lesion)-Standard (Details : {https://www.acmeonline.com code '4503' = '4503', given as 'Biopsy without Microscopic Description (1 Site/Lesion)-Standard'})

subject: Max Jones

effective: 02/03/2017

issued: 15/03/2017 8:13:08 AM

performer: Acme Animal Labs

resultsInterpreter: Sean Stover, BS, DVM, DABVP (Canine/Feline), DACVP

presentedForm:

DiagnosticReport/lipids/_history/1 Modified: 5/28/2019 2:45:05 PM +02:00

Lipid Report for Wile. E. COYOTE (MRN: 23453) issued 3-Mar 2009 14:26

Test                  Units       Value       Reference Range
Cholesterol           mmol/L      6.3         <4.5
Triglyceride          mmol/L      1.3         <2.0
HDL Cholesterol       mmol/L      1.3         >1.5
LDL Chol. (calc)      mmol/L      4.2         <3.0
      

Acme Laboratory, Inc signed: Dr Pete Pathologist

DiagnosticReport/lri-example/_history/1 Modified: 5/28/2019 2:45:05 PM +02:00

Generated Narrative with Details

id: lri-example

identifier: Placer Identifier = RP723234, Filler Identifier = 250401, Group = RFP 123456

basedOn: ServiceRequest/example

status: final

category: Laboratory (Details : {http://terminology.hl7.org/CodeSystem/v2-0074 code 'LAB' = 'Laboratory', given as 'Laboratory'}; {http://terminology.hl7.org/CodeSystem/v2-0074 code 'MB' = 'Microbiology', given as 'microbiology'})

code: Aerobic Respiratory Culture, Sputum (Details : {LOINC code '624-7' = 'Bacteria identified in Sputum by Respiratory culture', given as 'Bacteria Spt Resp Cul'})

subject: Patient/example

effective: 15/08/2016

issued: 18/08/2016 6:14:35 PM

performer: Organization/example

specimen: Specimen/example

result:

DiagnosticReport/micro/_history/1 Modified: 5/28/2019 2:45:13 PM +02:00

Generated Narrative with Details

id: micro

identifier: 290741144

basedOn: ServiceRequest/req

status: final

category: Microbiology (Details : {http://terminology.hl7.org/CodeSystem/v2-0074 code 'MB' = 'Microbiology)

code: Culture, MRSA (Details : {LOINC code '632-0' = 'Bacteria identified in Wound by Aerobe culture)

subject: Patient/example

issued: 10/08/2009 8:25:44 AM

performer: Todd Ashby

result: Observation/org1

DiagnosticReport/pap/_history/1 Modified: 5/28/2019 2:45:07 PM +02:00

Acme Anatomic Pathology Services
2216 Santa Monica Blvd, Suite 114
Santa Monica, CA 90404
===============================================================
GYN CYTOLOGY (PAP SMEAR) REPORT
===============================================================

Patient: Everywoman, Eve Report Date: 2/14/2013
DOB: 05/31/1973 Age: 30 Sex: F MRN: PATID14567
Patient Address: 2222 Home Street
Huntington Park
CA 90255
Order: ORD40
Physician: Careful, Adam 5742200012 (NPI)
SpecimenID: GHSID40
Collected Date: 2/11/2013
Received Date: 2/12/2013
LMP: 1/28/2013
Specimen Source: Cervical Cytology (ThinPrep)
Previously abnormal Pap? Unknown

Specimen Adequacy: Satisfactory
Diagnostic Interpretation: Epithelial cell abnormality: Atypical squamous cells
of undetermined significance
Hormonal Evaluations: not possible, due to presence of atypical cells
Recommendations: Appropriate Follow-up. Suggest repeat as clinically indicated
Comments: Abnormal report reviewed by pathologist for confirmation

DiagnosticReport/report/_history/1 Modified: 5/28/2019 2:45:11 PM +02:00

Generated Narrative with Details

id: report

status: final

code: comprehensive bone marrow report (Details )

subject: Everywoman, Eve A, MRN: 123456789

effective: 02/01/2015 1:20:10 PM

issued: 06/01/2015 1:20:10 PM

performer: Molecular Diagnostic Laboratory

specimen: Bone marrow ID: MLD45-Z4-1234

result:

DiagnosticReport/ultrasound/_history/1 Modified: 5/28/2019 2:45:07 PM +02:00

Generated Narrative with Details

id: ultrasound

status: final

category: Radiology (Details : {SNOMED CT code '394914008' = 'Radiology - speciality', given as 'Radiology'}; {http://terminology.hl7.org/CodeSystem/v2-0074 code 'RAD' = 'Radiology)

code: Abdominal Ultrasound (Details : {SNOMED CT code '45036003' = 'Ultrasonography of abdomen', given as 'Ultrasonography of abdomen'})

subject: Patient/example

effective: 01/12/2012 12:00:00 PM

issued: 01/12/2012 12:00:00 PM

performer: Practitioner/example

Media

- Comment Link
* A comment about the image WADO example image

conclusion: Unremarkable study