Case study 6 Suspected Melanoma, order for histopathology examination A 45-year-old female patient Simone Studer came for her regular skin check to the Arztpraxis of Dermatologist Armin Ahrens, and this lesion was noted: Junctions nevi consisting of seborrheic area top end and atypical network constructed of many seperate dots, structures , etc , suggesting melanocytic involvement. Excision. Attachement of dermatoscopic images Specimen: 29 x 11 x 5 mm skin ellipse Body Site: Back paralumbar left The skin sample, including the order form and the dermatoscopic image are sent to the laboratory.
Laboratory Order with ServiceRequest 6-histopath
Laboratory Order with Service Request 6-histopath
id: SimoneStuder meta: identifier: 80756011110123400008 name: SimoneStuder gender: FEMALE birthDate: Jan 08, 1992 maritalStatus: verheiratet (Details : {$ech-11-maritalstatus code '2' = '2', given as 'verheiratet'}) Communications - Language Preferred * Italienisch (Schweiz) (Details : {urn:ietf:bcp:47 code 'it-CH' = 'Italian (Region=Schweiz)) true
Generated Narrative: Practitioner ArminAhrens Profile: CH Core Practitioner identifier: GLN/7601000050700, urn:oid:2.16.756.5.30.1.123.100.2.1.1/G999999 name: Armin Ahrens (Official) telecom: ph: 033 123 22 11(Work), armin.ahrens@arztpraxis.ch Qualifications - Code * Dermatology and venereology
Generated Narrative: Organization Arztpraxis Profile: CH Core Organization identifier: GLN/7601000235503 name: Arztpraxis Messen telecom: +41555545566, info@arztpraxis.ch, http://www.arztpraxis.ch address: Doktorgasse 2 Messen 3254 CH
Generated Narrative: PractitionerRole ArminAhrensArztpraxis Profile: CH Core PractitionerRole practitioner: Practitioner Armin Ahrens (official) organization: Organization Arztpraxis Messen
Generated Narrative: Practitioner PeterPresto Profile: CH Core Practitioner EPR identifier: GLN/7601022050702, urn:oid:2.16.756.5.30.1.123.100.2.1.1/L248519 name: Peter Presto (Official) telecom: ph: 032 333 22 33(Work), peter.presto@arztpraxis.ch
Generated Narrative: Organization Gruppenpraxis Profile: CH Core Organization EPR identifier: GLN/7601000241115 name: Gruppenpraxis Olten telecom: +41555556677, info@gruppenpraxis.ch, http://www.gruppenpraxis.ch address: Gerbergasse 12 Olten 4600 CH
Generated Narrative: PractitionerRole PeterPrestoGruppenpraxis Profile: CH Core PractitionerRole practitioner: Practitioner Peter Presto (official) organization: Organization Gruppenpraxis Olten
Generated Narrative: Practitioner EvaErlenmeyer Profile: CH Core Practitioner identifier: GLN/7601000050717, urn:oid:2.16.756.5.30.1.123.100.2.1.1/Y274589 name: Eva Erlenmeyer (Official) telecom: ph: 033 444 55 66(Work), eva.erlenmeyer@labor-pipette.ch
Generated Narrative: Organization LaborPipette Profile: CH Core Organization identifier: GLN/7601000234407 name: Labor Pipette telecom: +41223345566, info@labor-pipette.ch, http://www.labor-pipette.ch address: Laborstrasse 23 Olten 4600 CH
Generated Narrative: PractitionerRole EvaErlenmeyerLaborPipette Profile: CH Core PractitionerRole identifier: urn:oid:2.16.756.5.30.1.123.100.2.1.1/K333333 practitioner: Practitioner Eva Erlenmeyer (official) organization: Organization Labor Pipette
Generated Narrative: Specimen Skin identifier: 48736-12345-75465 accessionIdentifier: 4e99a-12345-dd333 status: Available type: 29 x 11 x 5 mm skin ellipse subject: Simone Studer (official) Female, DoB: 1992-01-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400008) request: ServiceRequest Pathology study Collections - Collector Collected[x] BodySite * PractitionerRole 2015-08-16 06:40:17+0000 Entire skin of lumbar region of back (body structure) Containers - Type * General specimen receptacle transport container (physical object)
Specimen from skin obtained by elliptical excision (specimen)
Entire skin of lumbar region of back (body structure)
General specimen receptacle transport container (physical object)
Generated Narrative: DiagnosticReport skin-dermatoscopy Profiles: CH LAB-Order Diagnosic Report, DiagnosticReport Dermatoscopy of skin, Diagnostic Report (Pathology) Subject Simone Studer (official) Female, DoB: 1992-01-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400008) When For 2017-03-02 Reported 2025-05-01 10:00:00+0000 Performer Marc Mustermann, Arztpraxis Identifier http://example.org/identifiers/P44444444 Report Details
Pathology (gross & histopath, not surgical)
Optical dermatoscopy of skin (procedure)
Generated Narrative: Media skin-dermatoskopy-image status: Completed type: Image modality: Photographic image subject: Simone Studer (official) Female, DoB: 1992-01-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400008) created: 2023-12-17 issued: 2023-12-17 14:56:18+0000 operator: Practitioner Armin Ahrens (official) height: 661 width: 702 content id a1 contentType: image/png data: (base64 data - 433,968 base64 chars) creation: 2023-12-17
Generated Narrative: ServiceRequest 6-histopath-service-request Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 status: Active intent: Original Order priority: Urgent code: Pathology study subject: Simone Studer (official) Female, DoB: 1992-01-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400008) requester: PractitionerRole reasonCode: Suspicion Melanoma Skin reasonReference: Diagnostic Report for 'Optical dermatoscopy of skin (procedure)' for '->Simone Studer' specimen: Skin specimen
Pigmented nevus (morphologic abnormality)