Repositorio de Reportes de Biopsias Oncológicas, published by Unidad de Interoperabilidad - MINSAL. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Minsal-CL/riap/ and changes regularly. See the Directory of published versions

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: Informe de Anatomía Patológica de Biopsia de Mama - XML Representation

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<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="r2bo-informe-biopsia-ex"/>
  <meta>
    <profile
             value="https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-informe-biopsia"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: DiagnosticReport r2bo-informe-biopsia-ex</b></p><a name="r2bo-informe-biopsia-ex"> </a><a name="hcr2bo-informe-biopsia-ex"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-r2bo-informe-biopsia.html">Perfil del Reporte de Anatomía Patológica</a></p></div><h2><span title="Codes:{http://loinc.org 66110-8}">Informe de Biopsia de Mama</span> (<span title="Codes:{http://terminology.hl7.org/CodeSystem/v2-0074 PAT}">Pathology (gross &amp; histopath, not surgical)</span>) </h2><table class="grid"><tr><td>Subject</td><td>Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))</td></tr><tr><td>Reported</td><td>2021-08-01 10:00:00-0400</td></tr><tr><td>Performer</td><td> <a href="PractitionerRole-r2bo-anatopatologo-hospital.html">PractitionerRole MÉDICO CIRUJANO</a></td></tr><tr><td>Identifier</td><td> r2bo-2020-0001</td></tr></table><p><b>Report Details</b></p><table class="grid"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>Flags</b></td><td><b>When For</b></td></tr><tr><td><a href="Observation-r2bo-observacion-microscopica-ex.html"><span title="Codes:{http://loinc.org 102034-6}">Pathology report microscopic observation in Specimen</span></a></td><td>Se observa tejido mamario con células epiteliales y estromales, con signos de malignidad con metastasis en ganglios linfáticos</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-observacion-macroscopica-ex.html"><span title="Codes:{http://loinc.org 74574-5}">Macroscopic observation [Interpretation] in Specimen Narrative</span></a></td><td>Muestra de biopsia de tejido mamario, de 2x2x1 cm, de color blanco, consistencia firme, bordes irregulares, sin lesiones visibles a simple vista</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-estadificacion-tnm-ex.html"><span title="Codes:{http://snomed.info/sct 399588009}">399588009</span></a></td><td/><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-observacion-ganglios-linfaticos-ex.html"><span title="Codes:{http://loinc.org 92831-7}">Lymph nodes with metastasis [#] in Cancer specimen</span></a></td><td>true</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-observacion-infiltracion-perineural-ex.html"><span title="Codes:{http://snomed.info/sct 371513001}">371513001</span></a></td><td><span title="Codes:{http://snomed.info/sct 385001000}">385001000</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-observacion-infiltracion-peritumoral-ex.html"><span title="Codes:{http://snomed.info/sct 371509008}">371509008</span></a></td><td><span title="Codes:{http://snomed.info/sct 369762001}">369762001</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-observacion-invasion-linfatica-ex.html"><span title="Codes:{http://loinc.org 33739-4}">Lymphatic.small vessel.invasion [Identifier] in Specimen by CAP cancer protocols</span></a></td><td><span title="Codes:{http://snomed.info/sct 52101004}">52101004</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-observacion-invasion-vascular-ex.html"><span title="Codes:{http://loinc.org 33740-2}">Venous.large vessel.invasion [Identifier] in Specimen by CAP cancer protocols</span></a></td><td><span title="Codes:{http://snomed.info/sct 52101004}">52101004</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-observacion-margen-quirurgico-ex.html"><span title="Codes:{http://snomed.info/sct 396631001}">396631001</span></a></td><td/><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-observacion-centricidad-ex.html"><span title="Codes:{http://loinc.org 42030-7}">Multiple tumors reported as single primary Cancer</span></a></td><td>true</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-observacion-multifocalidad-ex.html"><span title="Codes:{http://snomed.info/sct 444696007}">444696007</span></a></td><td>true</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-observacion-porcentaje-necrosis-ex.html"><span title="Codes:{http://snomed.info/sct 405921002}">405921002</span></a></td><td>5 %<span style="background: LightGoldenRodYellow"> (Details: UCUM  code% = '%')</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-observacion-post-tratamiento-neoadjuvancia-ex.html"><span title="Codes:{http://loinc.org 84891-1}">Tumor response to neoadjuvant therapy</span></a></td><td>El tratamiento entregado no ha sido efectivo para reducir el tamaño del tumor, por lo que se recomienda un nuevo tratamiento.</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href="Observation-r2bo-tamano-tumor-ex.html"><span title="Codes:{http://loinc.org 21889-1}">Size Tumor</span></a></td><td/><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr></table><p>Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral</p><p><b>Coded Conclusions:</b></p><ul><li><span title="Codes:{http://snomed.info/sct 82711006}, {http://terminology.hl7.org/CodeSystem/icd-o-3 8500/3}">Carcinoma ductal infiltrante</span></li><li><span title="Codes:{http://snomed.info/sct 76752008}, {http://terminology.hl7.org/CodeSystem/icd-o-3 C50.9}">Mama</span></li></ul></div>
  </text>
  <identifier>
    <value value="r2bo-2020-0001"/>
  </identifier>
  <basedOn>🔗 
    <reference value="ServiceRequest/r2bo-solicitud-informe-apa-ej"/>
  </basedOn>
  <status value="final"/>
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>
      <code value="PAT"/>
      <display value="Pathology (gross &amp; histopath, not surgical)"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://loinc.org"/>
      <code value="66110-8"/>
    </coding>
    <text value="Informe de Biopsia de Mama"/>
  </code>
  <subject>🔗 
    <reference value="Patient/paciente-requiere-examen"/>
  </subject>
  <issued value="2021-08-01T10:00:00-04:00"/>
  <performer>🔗 
    <reference value="PractitionerRole/r2bo-anatopatologo-hospital"/>
  </performer>
  <specimen>🔗 
    <reference value="Specimen/r2bo-specimen-example"/>
  </specimen>
  <result>🔗 
    <reference value="Observation/r2bo-observacion-microscopica-ex"/>
  </result>
  <result>🔗 
    <reference value="Observation/r2bo-observacion-macroscopica-ex"/>
  </result>
  <result>🔗 
    <reference value="Observation/r2bo-estadificacion-tnm-ex"/>
  </result>
  <result>🔗 
    <reference value="Observation/r2bo-observacion-ganglios-linfaticos-ex"/>
  </result>
  <result>🔗 
    <reference
               value="Observation/r2bo-observacion-infiltracion-perineural-ex"/>
  </result>
  <result>🔗 
    <reference
               value="Observation/r2bo-observacion-infiltracion-peritumoral-ex"/>
  </result>
  <result>🔗 
    <reference value="Observation/r2bo-observacion-invasion-linfatica-ex"/>
  </result>
  <result>🔗 
    <reference value="Observation/r2bo-observacion-invasion-vascular-ex"/>
  </result>
  <result>🔗 
    <reference value="Observation/r2bo-observacion-margen-quirurgico-ex"/>
  </result>
  <result>🔗 
    <reference value="Observation/r2bo-observacion-centricidad-ex"/>
  </result>
  <result>🔗 
    <reference value="Observation/r2bo-observacion-multifocalidad-ex"/>
  </result>
  <result>🔗 
    <reference value="Observation/r2bo-observacion-porcentaje-necrosis-ex"/>
  </result>
  <result>🔗 
    <reference
               value="Observation/r2bo-observacion-post-tratamiento-neoadjuvancia-ex"/>
  </result>
  <result>🔗 
    <reference value="Observation/r2bo-tamano-tumor-ex"/>
  </result>
  <conclusion
              value="Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral"/>
  <conclusionCode id="Morfologico">
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="82711006"/>
    </coding>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/icd-o-3"/>
      <code value="8500/3"/>
    </coding>
    <text value="Carcinoma ductal infiltrante"/>
  </conclusionCode>
  <conclusionCode id="Topografico">
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="76752008"/>
    </coding>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/icd-o-3"/>
      <code value="C50.9"/>
    </coding>
    <text value="Mama"/>
  </conclusionCode>
</DiagnosticReport>