type: exampleresource: DiagnosticReportexample: diagnosticreport-example-dxa
DiagnosticReport Example: diagnosticreport-example-dxa
Narrative
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
Example XML
<?xml version="1.0" encoding="UTF-8"?>
<DiagnosticReport xmlns="http://hl7.org/fhir">
<id value="102"/>
<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>?BMD(g/cm2)</td>
<td>?BMD(%)</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 Henry Seven 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>
<status value="final"/><!-- femur, laterality = left --><!-- first, various administrative/context stuff --><code>
<coding>
<system value="http://loinc.org"/>
<code value="38269-7"/>
</coding>
<text value="DXA BONE DENSITOMETRY"/>
</code>
<subject>
<reference value="Patient/pat2"/>
</subject>
<effectiveDateTime value="2008-06-17"/><!-- all this report is final --><issued value="2008-06-18T09:23:00+10:00"/><!-- well, actually. this isn't the patient, but it'll do for now --><performer>
<reference value="Practitioner/3ad0687e-f477-468c-afd5-fcc2bf897809"/>
<display value="Dr Henry Seven"/>
</performer>
<result>
<reference value="Observation/bmd"/><!-- but just one for now, but for this example there should be more as listed here
<reference value="Observation/bmd1"/> (LEFT 24701-5 DXA Femur [Mass/Area] Bone densityO g/cm2)
<reference value="Observation/bmd2> (LEFT 8263-0 Femur DXA [T-score] Bone densityO {T-score})
<reference value="Observation/bmd3"/> (RIGHT 24701-5 DXA Femur [Mass/Area] Bone densityO g/cm2)
<reference value="Observation/bmd4"/> (RIGHT 38263-0 Femur DXA [T-score] Bone densityO {T-score})
<reference value="Observation/bmd5"/> (24966-4 Lumbar spine DXA Bone densityO g/cm2)
<reference value="Observation/bmd6"/> (38267-1 Lumbar spine DXA [T-score] Bone densityO {T-score})
--></result><!-- the imaging service marks this to help find categories of patient --><conclusionCode>
<coding>
<system value="http://snomed.info/sct"/>
<code value="391040000"/>
<display value="At risk of osteoporotic fracture"/>
</coding>
</conclusionCode>
</DiagnosticReport>