{ "resourceType" : "DiagnosticReport", "id" : "diagnosticreport-prostate-programme-report-example", "meta" : { "profile" : ["https://hl7.lt/fhir/prostate/StructureDefinition/prostate-report-lt-prostate"] }, "language" : "lt", "text" : { "status" : "generated", "div" : "

Lithuanian

Generated Narrative: DiagnosticReport diagnosticreport-prostate-programme-report-example

Language: en

Profile: DiagnosticReport: Prostate programme report (LT)

Imaging Report V0.0.1 (Diagnostic imaging study)

SubjectTomas Kazlauskas(official) Male, DoB: 1980-01-01 ( http://hospital-lt.lt/patient-id#HOSPLT-20001\u00a0(use:\u00a0usual,\u00a0))
When For2024-05-27 10:30:00+0000
Reported2024-05-27 10:35:00+0000
Performer PractitionerRole
Identifier https://hl7.lt/fhir/prostate/sid/diagnostic-report/PR-PROG-2024-0001

Report Details

CodeValueFlagsNoteWhen For
Morphologically abnormal structureFinal
Assessment using Prostate Imaging-Reporting and Data System (procedure) (Structure of anterior middle regional part of transition zone of right half prostate)5Final

Anterior transition zone lesion (~32 mm), extending across midline. Very high suspicion on mpMRI.

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T2 Weighted MR Signal Intensity5Final

T2 score 5 in transition zone lesion.

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Diffusion weighted5Final

Marked diffusion restriction (DWI score 5).

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Apparent Diffusion Coefficient5Final

Low ADC corresponding to restricted diffusion (ADC score 5).

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T1 Weighted Dynamic Contrast Enhanced MR Signal Intensity5Final

Dynamic contrast enhancement reported as positive (+).

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No mpMRI sequences are of diagnostic quality3Final2025-09-22 10:30:00+0000
PRECISE longitudinal assessmentPRECISE 3 - Stable diseaseFinal

Stable disease compared to prior MRI examinations.

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Gleason score (observable entity)ISUP Grade Group 1 (Gleason 3+3)Final

Histopathology shows Gleason score 3+3. Patient managed with active surveillance.

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2024-05-27 09:00:00+0000

PI-RADS 5 lesion; PI-QUAL adequate; PRECISE 3 stable. Programme imaging results in linked Observations.

\n
" }, "identifier" : [{ "system" : "https://hl7.lt/fhir/prostate/sid/diagnostic-report", "value" : "PR-PROG-2024-0001" }], "status" : "final", "category" : [{ "coding" : [{ "system" : "http://loinc.org", "code" : "18748-4", "display" : "Diagnostic imaging study" }] }], "code" : { "coding" : [{ "system" : "http://hl7.eu/fhir/imaging-r5/CodeSystem/Hl7EuDocumentTypes", "code" : "imaging-report-v0-0-1", "display" : "Imaging Report V0.0.1" }] }, "subject" : { "reference" : "Patient/patient-male-example" }, "encounter" : { "reference" : "Encounter/encounter-prostate-diagnostic-example" }, "effectiveDateTime" : "2024-05-27T10:30:00Z", "issued" : "2024-05-27T10:35:00Z", "performer" : [{ "reference" : "PractitionerRole/practitioner-role-radiologist-example" }], "result" : [{ "reference" : "Observation/imfinding-prostate-lesion1-example" }, { "reference" : "Observation/observation-prostate-pirads-lesion1-example" }, { "reference" : "Observation/observation-prostate-t2-score-lesion1-example" }, { "reference" : "Observation/observation-prostate-dwi-score-lesion1-example" }, { "reference" : "Observation/observation-prostate-adc-score-lesion1-example" }, { "reference" : "Observation/observation-prostate-dce-score-lesion1-example" }, { "reference" : "Observation/observation-prostate-piqual-example" }, { "reference" : "Observation/observation-prostate-precise-followup-example" }, { "reference" : "Observation/observation-prostate-gleason-gradegroup-example" }], "study" : [{ "reference" : "ImagingStudy/imagingstudy-prostate-mpmri-example" }], "supportingInfo" : [{ "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0936", "code" : "RSLT" }] }, "reference" : { "reference" : "Observation/observation-prostate-psa-example" } }, { "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0936", "code" : "RSLT" }] }, "reference" : { "reference" : "Observation/observation-prostate-volume-example" } }, { "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0936", "code" : "SCI" }] }, "reference" : { "reference" : "Observation/observation-prostate-psad-example" } }], "composition" : { "reference" : "Composition/composition-prostate-programme-example" }, "conclusion" : "PI-RADS 5 lesion; PI-QUAL adequate; PRECISE 3 stable. Programme imaging results in linked Observations." }