Lithuanian Cervical Cancer Implementation Guide
0.0.1 - ci-build Lithuania vėliava

Lithuanian Cervical Cancer Implementation Guide, published by Lithuanian Medical Library. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7LT/ig-lt-cervical/ and changes regularly. See the Directory of published versions

Pavyzdys QuestionnaireResponse: QuestionnaireResponse: Cervical Histopathology – HSIL/CIN2, Cone Biopsy (example)

Lithuanian

Language: en

LinkIDTextDefinitionAnswerdoco
.. qr-cervical-histology-espbi-exampleQuestionnaire:Cervical Histopathological Examination – ESPBI Form
... referralReferral to perform pathology test
.... referral.personalCodePersonal code48501019999
.... referral.nameNameJanette
.... referral.surnameSurnamePetrauskaite
.... referral.dateOfBirthDate of birth1985-01-01
.... referral.clinicalDiagnosisClinical diagnosis (ICD-10 code with name)N87.1 Moderate cervical dysplasia
... previousProceduresPrevious procedures history
.... previousProcedures.hasPreviousProcedureHas previous procedureSNOMED CT: 373066001 (Yes (qualifier value))
.... previousProcedures.procedureTypeType of previous procedureSNOMED CT: 50796003 (Cervical biopsy (procedure))
.... previousProcedures.procedureDateProcedure date2024-11-20
... colposcopyDataColposcopy examination data
.... colposcopyData.colposcopyStatusColposcopy statusSNOMED CT: 392003006 (Colposcopy performed)
.... colposcopyData.swedeScoreSwede score (0-10)7
.... colposcopyData.adequacyAdequacy of colposcopySNOMED CT: 125152006 (Specimen satisfactory for evaluation (finding))
... biopsyProcedureNature of operation/procedure
.... biopsyProcedure.procedureTypeProcedure typeSNOMED CT: 54535009 (Cone biopsy of cervix (procedure))
... biopsySitesBiopsy site description
.... biopsySites.containersContainer
..... biopsySites.containers.biopsySiteBiopsy siteSNOMED CT: 127900007 (Structure of left superior quadrant of uterine cervix)
..... biopsySites.containers.anatomicalNotesAnatomical notesCone biopsy specimen from transformation zone, left superior quadrant
..... biopsySites.containers.numberOfFragmentsNumber of fragments1
... macroscopicMacroscopic examination
.... macroscopic.tissueSizeXTissue size X (mm)18
.... macroscopic.tissueSizeYTissue size Y (mm)15
.... macroscopic.tissueSizeZTissue size Z (mm)12
.... macroscopic.ectocervixSizeXEctocervix size X (mm)16
.... macroscopic.ectocervixSizeYEctocervix size Y (mm)14
.... macroscopic.notesNotesCone biopsy specimen, grey-white tissue, well-oriented with ink marking at 12 o'clock position
... microscopicMicroscopic examination
.... microscopic.descriptionMicroscopic descriptionSections show high-grade squamous intraepithelial neoplasia (CIN2) involving the transformation zone. The dysplastic epithelium extends through the upper two-thirds of the squamous epithelium with increased nuclear-to-cytoplasmic ratio, nuclear hyperchromasia, and mitotic figures. No stromal invasion identified. Endocervical glands are unremarkable.
... conclusionConclusion / Diagnosis
.... conclusion.diagnosisCategoryDiagnosis categorySNOMED CT: 400049009 (Squamous intraepithelial neoplasia grade 2 (morphologic abnormality))
... gradeHistological grade
.... grade.gradeGradeSNOMED CT: 1228850007 (American Joint Committee on Cancer grade G2 (qualifier value))
... pLVILymphovascular invasion (pLVI)
.... pLVI.statuspLVI statusSNOMED CT: 373067005 (No (qualifier value))
... marginsSurgical margins
.... margins.marginStatusMargin statusSNOMED CT: 310342002 (Excision - clear margin (finding))
... tnmTNM staging
.... tnm.pTpT stageSNOMED CT: 1228953005 (American Joint Committee on Cancer pTis (qualifier value))
.... tnm.pRpR stageSNOMED CT: 1222638005 (American Joint Committee on Cancer R0 (qualifier value))
.... tnm.icd10CodeICD-10 codeD06.9
.... tnm.snomedCodeSNOMED CT code400049009
... conductedByConducted by
.... conductedBy.conductedNameNamePetras
.... conductedBy.conductedSurnameSurnameKazlauskas
.... conductedBy.conductedPressNumberMedical press numberMED-LT-54321
.... conductedBy.responseDateResponse date2025-04-15T14:30:00+03:00
... confirmedByConfirmed by
.... confirmedBy.confirmedNameNameRuta
.... confirmedBy.confirmedSurnameSurnameJonaite
.... confirmedBy.confirmedPressNumberMedical press numberMED-LT-67890
.... confirmedBy.confirmationDateConfirmation date2025-04-16T09:00:00+03:00

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