Bundle MHDTransactionBundleKneeMriExample of type transaction

Entry 1 - fullUrl = DocumentReference/1

Resource DocumentReference:

Profile: Report Obligations for ImReportIheMhdDocumentReference

identifier: Uniform Resource Identifier (URI)/MRIKneeReportexample (use: official, )

status: Current

modality: US

type: Imaging Manifest V0.0.1

category: Diagnostic imaging study

subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000

BodySites

-	Concept
*	Right knee

author: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000

custodian: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000

content

Attachments

-	ContentType	Language	Url	Creation
*	application/pdf	en	Bundle: type = transaction; timestamp = 1993-11-29 12:36:56+0000	2024-01-01 00:00:00+0000

Profiles

-	Value[x]
*	Bundle: Imaging Report

Request:

PUT DocumentReference/1

Entry 2 - fullUrl = Bundle/1

Resource Bundle:

Document Details

Profile: Bundle: Imaging Report

Final Document at 2021-01-01 00:00:00+0000 by Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000, Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 for Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000

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Document Subject

Profile: Patient (EU core)

John Smith Male, DoB: 1995-05-05 ( Medical Record number: 12345 (use: usual, ))

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Document Content

Technique

Axial PD fat sat, coronal T1, coronal PD fat sat, coronal T2 fat sat, sagittal PD, and sagittal PD fat sat images were performed

Clinical information

Evaluate medial left knee pain. Injured playing football 3 weeks ago. Positive Lachman test. Evaluate ACL tear. Evaluate for meniscal tear.

History

Injured playing football 3 weeks ago.

Contrast

None utilized.

Comparison

None available

Findings

FLUID: Moderate effusion. MENISCI: Medial: No evidence of a tear. Lateral: Peripheral vertical tear in the posterior horn of the lateral meniscus at the ligament of Wrisberg attachment. CRUCIATE LIGAMENTS: Complete tear of the ACL, which is torn in the mid substance. The posterior cruciate ligament is intact. COLLATERAL LIGAMENTS: Grade 1 to grade 2 MCL sprain. There is edema in the deep fibers, as well as some in the in the superficial fibers and in the adjacent soft tissues. Edema extends anteriorly to the region of the medial patellofemoral ligament attachment to the adductor tubercle where the injury is intermediate grade in character. The lateral collateral ligament complex is intact. Edema is noted in the popliteus muscle belly and muscle-tendon junction as well as the popliteal fibular ligament region also reflective of an intermediate grade injury. EXTENSOR MECHANISM: Intact. CARTILAGE: Patellofemoral compartment: No chondral defect or area of high-grade chondral loss. Medial tibiofemoral compartment: No chondral defect or area of high-grade chondral loss. Lateral tibiofemoral compartment: No chondral defect or area of high-grade chondral loss. BONE MARROW: Bone marrow contusions are seen in the posterior medial and lateral proximal tibia as well as the mid lateral femoral condyle extending anteriorly. There is a contusion in the anterior lateral proximal tibia and as well in the proximal fibula. There is an additional contusion along the inferior pole of the patella.

Impressions

1. Moderate effusion. 2. Peripheral vertical tear in the posterior horn of the lateral meniscus at the ligament of Wrisberg attachment. 3. Complete tear of the ACL. 4. Grade 1 to grade 2 MCL complex sprain as described above. 5. Edema extends anteriorly to the region of the medial patellofemoral ligament attachment to the adductor tubercle where the injury is intermediate grade in character. Edema is noted in the popliteus muscle belly and muscle tendon junction as well as the popliteal fibular ligament region also reflective of an intermediate grade injury. 6. Bone marrow contusions are seen in the posterior medial and lateral proximal tibia as well as the mid lateral femoral condyle extending anteriorly. There is a contusion in the anterior lateral proximal tibia and as well in the proximal fibula. There is an additional contusion along the inferior pole of the patella.

Recommendations

None.

Communications

None.

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Additional Resources Included in Document

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Entry 2 - fullUrl = ImagingStudy/1

Resource ImagingStudy:

Profile: ImagingStudy: General

identifier: Study Instance UID/999.999.3859744

status: Available

modality: Magnetic Resonance

subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000

started: 2011-01-01

referrer: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000

series

uid: 999.999.94827453

modality: Magnetic Resonance

description: Axial PD fat sat

Instances

-	Uid	SopClass	Number
*	999.999.133.1996.1.1800.1.6.9	unknown 1.2.840.10008.5.1.4.1.1.6.1: 1.2.840.10008.5.1.4.1.1.6.1	8

series

uid: 999.999.94827454

modality: Magnetic Resonance

description: Coronal T1

Instances

-	Uid	SopClass	Number
*	999.999.133.1996.1.1800.1.6.21	unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1	20

series

uid: 999.999.94827455

modality: Magnetic Resonance

description: Coronal PD fat sat

Instances

-	Uid	SopClass	Number
*	999.999.133.1996.1.1800.1.6.7	unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1	6

series

uid: 999.999.94827456

modality: Magnetic Resonance

description: Coronal T2 fat sat

Instances

-	Uid	SopClass	Number
*	999.999.133.1996.1.1800.1.6.11	unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1	10

series

uid: 999.999.94827457

modality: Magnetic Resonance

description: Sagital PD

Instances

-	Uid	SopClass	Number
*	999.999.133.1996.1.1800.1.6.15	unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1	14

series

uid: 999.999.94827458

modality: Magnetic Resonance

description: Sagital PD fat sat

Instances

-	Uid	SopClass	Number
*	999.999.133.1996.1.1800.1.6.17	unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1	16

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Entry 3 - fullUrl = Patient/1

Resource Patient:

Profile: Patient (EU core)

John Smith Male, DoB: 1995-05-05 ( Medical Record number: 12345 (use: usual, ))

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Entry 4 - fullUrl = Practitioner/1

Resource Practitioner:

Profile: Practitioner (EU base)

name: NationalRadMusculoskeletal

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Entry 5 - fullUrl = Organization/1

Resource Organization:

name: City Medical Imaging Center

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Entry 6 - fullUrl = ServiceRequest/1

Resource ServiceRequest:

Profile: ServiceRequest: Imaging Order

status: Draft

intent: Order

category: Imaging (procedure)

subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000

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Entry 7 - fullUrl = Procedure/1

Resource Procedure:

Profile: Procedure: Imaging Acquisition

status: Completed

code: MRI of the knee

subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000

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Entry 8 - fullUrl = Impression/1

Resource Condition:

Profile: Condition: EU Condition

clinicalStatus: active

subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000

---

Entry 9 - fullUrl = Finding/1

Resource Observation:

Profile: Observation: Imaging Finding

status: Final

code: Clinical finding

effective: 1993-11-29 12:36:56+0000

value: Complete tear of the ACL, which is torn in the mid substance

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Entry 10 - fullUrl = DiagnosticReport/1

Resource DiagnosticReport:

Profile: DiagnosticReport: Imaging Report

Imaging Report V0.0.1 (Diagnostic imaging study)

Subject	Not done yet
Reported	2021-01-01 00:00:00+0000
Performer	Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000

Report Details

Request:

PUT ImagingReport/1