Lithuanian Laboratory Implementation Guide
0.0.1 - ci-build Lithuania vėliava

Lithuanian Laboratory 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-lab/ and changes regularly. See the Directory of published versions

Pavyzdys DiagnosticReport: DiagnosticReport: Pathology Report (example)


Lithuanian


Histologic test (procedure)

SubjectJonas Petrauskas(official) Male, DoB: 1985-01-01 ( http://hospital-lt.lt/patient-id#HOSPLT-10005 (use: usual, ))
When For2022-10-25 13:35:00+0100
Performer Practitioner Registrar
Identifier http://hospital.lt/sid/pathology-report-number/3f69e0a5-2177-4540-baab-7a5d0877428f

Report Details

CodeValueFlagsNoteWhen For
Adequacy of specimen (observable entity)Specimen satisfactory for evaluation (finding)Final, normal

The breast tissue specimen is deemed adequate for histopathological evaluation.

2025-01-15 11:00:00+0200
The observation 'Observation/observation-estrogen-status' could not be resolved
The observation 'Observation/observation-progesterone-status' could not be resolved
ERBB2 gene duplication [Presence] in Tissue by FISHHer2 overexpressed or gene amplifiedFinal
Specimen sizeFinal2024-06-01 10:00:00+0000
Neoplasm observable (observable entity)Final2025-01-10 09:15:00+0200
Tumor sizeFinal2024-06-01 10:00:00+0000

Histopathological examination of the breast tissue specimens confirms the presence of invasive ductal carcinoma in the right breast and benign fibrocystic changes in the left breast.

Coded Conclusions:

  • Anterior surface of epiglottis