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Diagnosticreport-example-dxa.xml

Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner

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

<?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  Femur DXA 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  Femur DXA 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> 

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.