HL7 Europe Imaging Study Report, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 0.1.1-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/imaging/ and changes regularly. See the Directory of published versions
<DiagnosticReport xmlns="http://hl7.org/fhir">
<id value="DiagnosticReportStructured"/>
<meta>
<profile
value="http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImDiagnosticReport"/>
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-GB" lang="en-GB">
<div>
<table class="grid dict">
<tr>
<th scope="row"><b>Id: </b></th>
<td>DiagnosticReportStructured</td>
</tr>
<tr>
<th scope="row"><b>Code: </b></th>
<td>
<p style="margin-bottom: 5px;">
<span>transthoracic echocardiogram</span>
<span>(</span>
<span><a href="http://terminology.hl7.org/6.5.0/CodeSystem-CPT.html">http://www.ama-assn.org/go/cpt</a>:</span>
<span>93351</span>
<span>)</span>
</p>
</td>
</tr>
<tr>
<th scope="row">
<b>
Identifier:
</b>
</th>
<td>
<p style="margin-bottom: 5px;">
<span><a href="http://example.org/myhosptital/reportidentifiers">http://example.org/myhosptital/reportidentifiers</a>: </span>
<span>dfkjewoieoijwoskdjf</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>BasedOn: </b></th>
<td>Identifier: Accession ID/87654321</td>
</tr>
<tr>
<th scope="row"><b>Status: </b></th>
<td>final</td>
</tr>
<tr>
<th scope="row"><b>Category: </b></th>
<td>
<p style="margin-bottom: 5px;">
<span>Cardiac Ultrasoundy</span>
<span>(</span>
<span><a href="http://terminology.hl7.org/5.0.0/CodeSystem-v2-0074.html">http://terminology.hl7.org/CodeSystem/v2-0074</a>:</span>
<span>CUS</span>
<span>)</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Subject: </b></th>
<td><a href="Patient-PatientStructuredReport.html">3D TEE 2D(official) (no stated gender), DoB: 1976-04-29 ( 00 CARDIAC 2)</a> </td>
</tr>
<tr>
<th scope="row"><b>Period: </b></th>
<td>2003-06-01</td>
</tr>
<tr>
<th scope="row"><b>Performer: </b></th>
<td>
<p><a href="Organization-OrganizationStructuredReport.html">Organization Ultrasound centrum</a></p>
</td>
</tr>
<tr>
<th scope="row"><b>Results Interpreter: </b></th>
<td>
<p><a href="PractitionerRole-PractitionerRoleStructuredReportAuthor.html">PractitionerRole Cardiology</a></p>
</td>
</tr>
<tr>
<th scope="row"><b>Studies: </b></th>
<td>
<ul>
<li><a href="ImagingStudy-ImagingStudStructuredReport.html">ImagingStudy: identifier = Study Instance UID: DUI#urn:oid:1.3.46.670589.58.10.10562925256214266678.11674839624289915183; status = available; modality = Ultrasound; started = 2025-04-29</a></li>
</ul>
</td>
</tr>
<tr>
<th scope="row"><b>Composition: </b></th>
<td>
<a href="Composition-CompositionStructured.html">Transthoracic echocardiogram</a>
</td>
</tr>
<tr>
<th scope="row"><b>Results interpreter: </b></th>
<td>
<ul>
<li><a href="Observation-RestWmsi01.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi02.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi03.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi04.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi05.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi06.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi07.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi08.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi09.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi10.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi12.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi13.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi14.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi15.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi16.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-RestWmsi17.html">Observation Views first pass+wall motion^at rest+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi01.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi02.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi03.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi04.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi05.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi06.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi07.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi08.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi09.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi10.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi12.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi13.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi14.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi15.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi16.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
<li><a href="Observation-StressWmsi17.html">Observation Views first pass+wall motion^W stress+W radionuclide IV</a></li>
</ul>
</td>
</tr>
<tr>
<th scope="row"><b>Note: </b></th>
<td>
<p style="margin-bottom: 5px;">
<span>Procedure findings Narrative</span>
<span>(</span>
<span><a href="https://loinc.org/">http://loinc.org</a>:</span>
<span>59776-5</span>
<span>)</span>
</p>
<div><p><strong>Stress Findings</strong>
Normal baseline electrocardiogram. There was a maximum 1.5mm ST segment depression. The patient exhibited a hypertensive response with stress.</p>
</div>
</td>
</tr>
<tr>
<th scope="row"><b>Note: </b></th>
<td>
<p style="margin-bottom: 5px;">
<span>Procedure findings Narrative</span>
<span>(</span>
<span><a href="https://loinc.org/">http://loinc.org</a>:</span>
<span>59776-5</span>
<span>)</span>
</p>
<div><p><strong>Right Ventricle</strong>
The right ventricle is not well visualized. There is mild right ventricular hypertrophy.</p>
</div>
</td>
</tr>
<tr>
<th scope="row"><b>Note: </b></th>
<td>
<p style="margin-bottom: 5px;">
<span>Procedure findings Narrative</span>
<span>(</span>
<span><a href="https://loinc.org/">http://loinc.org</a>:</span>
<span>59776-5</span>
<span>)</span>
</p>
<div><p><strong>Atria</strong>
A patent foramen ovale is present and there is low risk for embolism. The left atrium is small.</p>
</div>
</td>
</tr>
<tr>
<th scope="row"><b>Note: </b></th>
<td>
<p style="margin-bottom: 5px;">
<span>Procedure findings Narrative</span>
<span>(</span>
<span><a href="https://loinc.org/">http://loinc.org</a>:</span>
<span>59776-5</span>
<span>)</span>
</p>
<div><p>Mitral Valve
The mitral valve leaflets appear normal. There is no evidence of stenosis, fluttering, or prolapse. Mitral valve prolapse cannot be excluded. No significant mitral valve stenosis. The mitral regurgitant jet is posteriorly directed, which is consistent with anterior leaflet pathology. There is a porcine mitral valve.</p>
</div>
</td>
</tr>
<tr>
<th scope="row"><b>Note: </b></th>
<td>
<p style="margin-bottom: 5px;">
<span>Procedure findings Narrative</span>
<span>(</span>
<span><a href="https://loinc.org/">http://loinc.org</a>:</span>
<span>59776-5</span>
<span>)</span>
</p>
<div><p><strong>Tricuspid Valve</strong>
The tricuspid valve leaflets are thickened and/or calcified, but open well. There is a ruptured tricuspid valve chordae with a flail free wall leaflet. No significant tricuspid stenosis. There is mild to moderate tricuspid regurgitation. The prosthetic tricuspid valve is not well visualized.</p>
</div>
</td>
</tr>
<tr>
<th scope="row"><b>Note: </b></th>
<td>
<p style="margin-bottom: 5px;">
<span>Procedure findings Narrative</span>
<span>(</span>
<span><a href="https://loinc.org/">http://loinc.org</a>:</span>
<span>59776-5</span>
<span>)</span>
</p>
<div><p><strong>Aortic Valve</strong>
The aortic valve is trileaflet. The aortic valve is normal in structure and function. Cannot exclude aortic valvular vegetation. Hemodynamically significant valvular aortic stenosis cannot be excluded. No aortic regurgitation is present. The prosthetic aortic valve is not well visualized.</p>
</div>
</td>
</tr>
<tr>
<th scope="row"><b>Note: </b></th>
<td>
<p style="margin-bottom: 5px;">
<span>Procedure findings Narrative</span>
<span>(</span>
<span><a href="https://loinc.org/">http://loinc.org</a>:</span>
<span>59776-5</span>
<span>)</span>
</p>
<div><p><strong>Pulmonic Valve</strong>
The pulmonic valve is normal in structure and function. A pulmonic valvular vegetation cannot be excluded. Infundibular pulmonic stenosis is noted. There is no pulmonic valvular regurgitation. The prosthetic pulmonic valve is well‐seated.</p>
</div>
</td>
</tr>
<tr>
<th scope="row"><b>Note: </b></th>
<td>
<p style="margin-bottom: 5px;">
<span>Procedure findings Narrative</span>
<span>(</span>
<span><a href="https://loinc.org/">http://loinc.org</a>:</span>
<span>59776-5</span>
<span>)</span>
</p>
<div><p><strong>Vessels</strong>
The aortic root is not well visualized but is probably normal size. Type B aortic dissection. The pulmonary artery is normal size.</p>
</div>
</td>
</tr>
<tr>
<th scope="row"><b>Note: </b></th>
<td>
<p style="margin-bottom: 5px;">
<span>Procedure findings Narrative</span>
<span>(</span>
<span><a href="https://loinc.org/">http://loinc.org</a>:</span>
<span>59776-5</span>
<span>)</span>
</p>
<div><p><strong>Pericardium</strong>
There is pericardial thickening and/or a small pericardial effusion. Large left pleural effusion.</p>
</div>
</td>
</tr>
<tr>
<th scope="row"><b>Conclusion: </b></th>
<td>
<div><p>This was a normal stress echocardiogram.
Nothing wrong with this patient
See you next year.</p>
</div>
</td>
</tr>
<tr>
<th scope="row"><b>Presented form: </b></th>
<td>
<ul>
<li>application/pdf @ ./Binary/structured-pdf</li>
</ul>
</td>
</tr>
</table>
</div>
</div>
</text>
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<valueReference>🔗
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<extension
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<valueReference>🔗
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<identifier>
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<system value="http://www.ama-assn.org/go/cpt"/>
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Normal baseline electrocardiogram. There was a maximum 1.5mm ST segment depression. The patient exhibited a hypertensive response with stress."/>
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<text
value="**Right Ventricle**
The right ventricle is not well visualized. There is mild right ventricular hypertrophy."/>
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<text
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A patent foramen ovale is present and there is low risk for embolism. The left atrium is small."/>
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value="Mitral Valve
The mitral valve leaflets appear normal. There is no evidence of stenosis, fluttering, or prolapse. Mitral valve prolapse cannot be excluded. No significant mitral valve stenosis. The mitral regurgitant jet is posteriorly directed, which is consistent with anterior leaflet pathology. There is a porcine mitral valve."/>
</note>
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<coding>
<system value="http://loinc.org"/>
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value="**Tricuspid Valve**
The tricuspid valve leaflets are thickened and/or calcified, but open well. There is a ruptured tricuspid valve chordae with a flail free wall leaflet. No significant tricuspid stenosis. There is mild to moderate tricuspid regurgitation. The prosthetic tricuspid valve is not well visualized."/>
</note>
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<coding>
<system value="http://loinc.org"/>
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value="**Aortic Valve**
The aortic valve is trileaflet. The aortic valve is normal in structure and function. Cannot exclude aortic valvular vegetation. Hemodynamically significant valvular aortic stenosis cannot be excluded. No aortic regurgitation is present. The prosthetic aortic valve is not well visualized."/>
</note>
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<coding>
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<text
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The pulmonic valve is normal in structure and function. A pulmonic valvular vegetation cannot be excluded. Infundibular pulmonic stenosis is noted. There is no pulmonic valvular regurgitation. The prosthetic pulmonic valve is well‐seated."/>
</note>
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value="**Vessels**
The aortic root is not well visualized but is probably normal size. Type B aortic dissection. The pulmonary artery is normal size."/>
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<text
value="**Pericardium**
There is pericardial thickening and/or a small pericardial effusion. Large left pleural effusion."/>
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<study>🔗
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<composition>🔗
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<conclusion
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Nothing wrong with this patient
See you next year."/>
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