Lithuanian

Generated Narrative: QuestionnaireResponse qr-cervical-colposcopy-espbi-example

Language: en

LinkIDTextDefinitionAnswerdoco
.. qr-cervical-colposcopy-espbi-exampleQuestionnaire:Questionnaire: Cervical Colposcopy ESPBI Form
... patientPatient identification
.... patient.personalCodePersonal code48501019999
.... patient.nameNameJanette
.... patient.surnameSurnamePetrauskaite
... clinicalHistoryPrevious test history
.... clinicalHistory.previousColposcopyPrevious colposcopy performedSNOMED CT: 373067005 (No (qualifier value))
.... clinicalHistory.indicationIndication (reason for colposcopy)HPV 16 positive, ASC-US cytology result
... colposcopyPerformedColposcopy procedure
.... colposcopyPerformed.performedColposcopy performedSNOMED CT: 398166005 (Performed (qualifier value))
.... colposcopyPerformed.procedureDateProcedure date2025-03-15
.... colposcopyPerformed.anesthesiaAnesthesia usedSNOMED CT: 373067005 (No (qualifier value))
... adequacyColposcopy adequacy
.... adequacy.adequateAdequacy of colposcopySNOMED CT: 398166005 (Performed (qualifier value))
... swedeScoreSwede score (0-10)
.... swedeScore.acetoWhiteReactionAcetowhite reaction (0-2)1
.... swedeScore.marginsAndSurfaceMargins and surface (0-2)0
.... swedeScore.vesselsVessels (0-2)1
.... swedeScore.lesionSizeLesion size (0-2)1
.... swedeScore.iodineStainingIodine staining (0-2)0
.... swedeScore.totalScoreTotal Swede score (0-10)3
... riskRisk assessment based on Swede score
.... risk.riskLevelRisk levelSNOMED CT: 723505004 (Low risk (qualifier value))
... biopsyProcedureBiopsy procedure
.... biopsyProcedure.biopsyPerformedBiopsy performedSNOMED CT: 373066001 (Yes (qualifier value))
.... biopsyProcedure.procedureTypeBiopsy procedure typeSNOMED CT: 51675008 (Punch biopsy of cervix (procedure))
... biopsySiteBiopsy site
.... biopsySite.siteBiopsy siteSNOMED CT: 127900007 (Left superior quadrant of uterine cervix)
.... biopsySite.notesNotesAcetowhite area at 10 o'clock position, approximately 5 mm
... impressionColposcopic impression
.... impression.impressionColposcopic impressionMinor acetowhite changes in the transformation zone at 10 o'clock. No atypical vessels. Transformation zone type 1.
.... impression.recommendationRecommendationAwait biopsy result. Follow-up in 6 months with HPV co-testing.
... signaturesSignatures
.... signatures.examinerNameExaminer nameJonas
.... signatures.examinerSurnameExaminer surnameKazlauskas
.... signatures.examinerPressNumberExaminer press numberLT-GYN-2024-0042
.... signatures.examDateExamination date2025-03-15T10:30:00+02:00

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