Instance: PatientKimMusterperson InstanceOf: Patient // or MII Patient, but then I guess I have to import it? Usage: #example * birthDate = 1956-03-14 * name.family = "Musterperson" * name.given = "Kim" // 20.04.22 CT T/A: // - [x] Z.n. atypischer Lebersegmentresektion, kein eindeutiger Hinweis auf Metastasierung. Flüssigkeitskollektion angrenzend DD postoperativ // - [x] kein Aszites // - [x] kein Hinweis auf Lokalrezidiv // - [x] kein Hinweis auf thorakale Metastasierung Instance: PatientKimMusterperson-Procedure-1 InstanceOf: MII_PR_Prozedur_Procedure Usage: #example Description: "20.04.22 CT T/A" * status = #completed * subject = Reference(PatientKimMusterperson) * code.coding = $OPS#3-20 "Native Computertomographie" * performedDateTime = 2022-04-20 * bodySite[+] = $SCT#4120138 "Abdomen" * bodySite[+] = $SCT#37542245 "Thorax" Instance: PatientKimMusterperson-Observation-1 InstanceOf: Observation Usage: #example Description: "kein Hinweis auf thorakale Metastasierung" * partOf = Reference(PatientKimMusterperson-Procedure-1) * status = #final * code.coding = $SCT#128462008 "Metastatic malignant neoplasm (disorder)" * valueCodeableConcept.coding = $SCT#41647002 "No evidence of (contextual qualifier) (qualifier value)" * valueCodeableConcept.text = "kein Hinweis auf thorakale Metastasierung" Instance: PatientKimMusterperson-Observation-2 InstanceOf: Observation Usage: #example Description: "kein Hinweis auf Lokalrezidiv" * partOf = Reference(PatientKimMusterperson-Procedure-1) * status = #final * code.coding = $SCT#255227004 "Recurrent" * valueCodeableConcept.coding = $SCT#41647002 "No evidence of (contextual qualifier) (qualifier value)" * valueCodeableConcept.text = "kein Hinweis auf Lokalrezidiv" Instance: PatientKimMusterperson-Observation-3 InstanceOf: Observation Usage: #example Description: "kein Aszites" * partOf = Reference(PatientKimMusterperson-Procedure-1) * status = #final * code.coding = $SCT#389026000 "Acites" * valueCodeableConcept.coding = $SCT#860638000 "No ascites" * valueCodeableConcept.text = "kein Aszites" Instance: PatientKimMusterperson-Observation-4 InstanceOf: Observation Usage: #example Description: "Z.n. atypischer Lebersegmentresektion, kein eindeutiger Hinweis auf Metastasierung. Flüssigkeitskollektion angrenzend DD postoperativ" * partOf = Reference(PatientKimMusterperson-Procedure-1) * status = #final * code.coding[+] = $SCT#237679004 "Status post (contextual qualifier) (qualifier value)" * code.coding[+] = $SCT#112231000 "Atypical (qualifier value)" * code.coding[+] = $SCT#174430004 "Resection of segment of liver (procedure)" * valueCodeableConcept.coding[+] = $SCT#801911000000107 "Collection of fluid" * valueCodeableConcept.coding[+] = $SCT#262061000 "After surgery" * valueCodeableConcept.text = "Flüssigkeitskollektion angrenzend DD postoperativ" * bodySite = $SCT#181247007 "Entire duodenum" // 15.07.22 CT T/A: // - [x] konstante Flüssigkeitskollektion angrenzend bei Z.n. atpyischer Lebersegmentresktion, a.e. postoperativ // - [x] kein Aszites, kein Hinweis auf Lokalrezidiv // - [x] im linken Oberlappen der Lunge diskrete milchglasartige Trübung DD atypisch entzündlich, klinische Korrelation empfohlen, darüber hinaus kein Hinweis auf thorakale Filiae Instance: PatientKimMusterperson-Procedure-2 InstanceOf: MII_PR_Prozedur_Procedure Usage: #example Description: "15.07.22 CT T/A" * status = #completed * subject = Reference(PatientKimMusterperson) * code.coding = $OPS#3-20 "Native Computertomographie" * performedDateTime = 2022-07-15 * bodySite[+] = $SCT#4120138 "Abdomen" * bodySite[+] = $SCT#37542245 "Thorax" Instance: PatientKimMusterperson-Observation-5 InstanceOf: Observation Usage: #example Description: "konstante Flüssigkeitskollektion angrenzend bei Z.n. atpyischer Lebersegmentresktion, a.e. postoperativ" * partOf = Reference(PatientKimMusterperson-Procedure-2) * status = #final * code.coding[+] = $SCT#237679004 "Status post (contextual qualifier) (qualifier value)" * code.coding[+] = $SCT#112231000 "Atypical (qualifier value) " * code.coding[+] = $SCT#174430004 "Resection of segment of liver (procedure)" * valueCodeableConcept.coding[+] = $SCT#420341009 "Constant" * valueCodeableConcept.coding[+] = $SCT#801911000000107 "Collection of fluid" * valueCodeableConcept.text = "konstante Flüssigkeitskollektion angrenzend" * bodySite = $SCT#181247007 "Entire duodenum" Instance: PatientKimMusterperson-Observation-6 InstanceOf: Observation Usage: #example Description: "kein Aszites" * partOf = Reference(PatientKimMusterperson-Procedure-2) * status = #final * code.coding = $SCT#389026000 "Acites" * valueCodeableConcept.coding = $SCT#860638000 "No ascites" * valueCodeableConcept.text = "kein Aszites" Instance: PatientKimMusterperson-Observation-7 InstanceOf: Observation Usage: #example Description: "kein Hinweis auf Lokalrezidiv" * partOf = Reference(PatientKimMusterperson-Procedure-2) * status = #final * code.coding = $SCT#255227004 "Recurrent" * valueCodeableConcept.coding = $SCT#41647002 "No evidence of (contextual qualifier) (qualifier value)" * valueCodeableConcept.text = "kein Hinweis auf Lokalrezidiv" Instance: PatientKimMusterperson-Observation-8 InstanceOf: Observation Usage: #example Description: "im linken Oberlappen der Lunge diskrete milchglasartige Trübung DD atypisch entzündlich, klinische Korrelation empfohlen, darüber hinaus kein Hinweis auf thorakale Filiae" * partOf = Reference(PatientKimMusterperson-Procedure-2) * status = #final * code.coding[+] = $SCT#112231000 "Atypical" * code.coding[+] = $SCT#1217294009 "Ground glass opacity" * code.coding[+] = $SCT#44714003 "Structure of upper lobe of left lung" * code.text = "im linken Oberlappen der Lunge diskrete milchglasartige Trübung" * valueCodeableConcept.coding = $SCT#41647002 "No evidence of (contextual qualifier) (qualifier value)" * valueCodeableConcept.coding[+] = $SCT#255058005 "Neoplasm of thorax" * valueCodeableConcept.text = "kein Hinweis auf thorakale Filiae" // 19.10.22 CT T/A // - [x] regrediente Flüssigkeitskollektion am Leberrand, Z.n. atypische Lebersegmentresektion. Darüberhinaus kein Hinweis auf Leberfilialisierung. // - [x] kein Aszites, kein Hinweis auf Lokalrezidiv // - [x] regrediente Milchglasinfiltrate im linken Oberlappen, somit a.e. atypisch entzündlich. Leicht vermehrter mediastinaler Lymphknotenbesatz ohne Kontrastmittelaufnahme und ohne pathologische Vergrößerung, Verlaufskontrolle empfohlen Instance: PatientKimMusterperson-Procedure-3 InstanceOf: MII_PR_Prozedur_Procedure Usage: #example Description: "19.10.22 CT T/A" * status = #completed * subject = Reference(PatientKimMusterperson) * code.coding = $OPS#3-20 "Native Computertomographie" * performedDateTime = 2022-10-22 * bodySite[+] = $SCT#4120138 "Abdomen" * bodySite[+] = $SCT#37542245 "Thorax" Instance: PatientKimMusterperson-Observation-9 InstanceOf: Observation Usage: #example Description: "regrediente Flüssigkeitskollektion am Leberrand, Z.n. atypische Lebersegmentresektion. Darüberhinaus kein Hinweis auf Leberfilialisierung." * partOf = Reference(PatientKimMusterperson-Procedure-3) * status = #final * code.coding[+] = $SCT#237679004 "Status post (contextual qualifier) (qualifier value)" * code.coding[+] = $SCT#112231000 "Atypical (qualifier value) " * code.coding[+] = $SCT#174430004 "Resection of segment of liver (procedure)" * valueCodeableConcept.coding[+] = $SCT#801911000000107 "Collection of fluid" * valueCodeableConcept.coding[+] = $SCT#249567002 "Liver edge (finding)" * valueCodeableConcept.text = "regrediente Flüssigkeitskollektion am Leberrand" * bodySite = $SCT#181268008 "Entire liver" Instance: PatientKimMusterperson-Observation-10 InstanceOf: Observation Usage: #example Description: "regrediente Flüssigkeitskollektion am Leberrand, Z.n. atypische Lebersegmentresektion. Darüberhinaus kein Hinweis auf Leberfilialisierung." * partOf = Reference(PatientKimMusterperson-Procedure-3) * status = #final * code.coding[+] = $SCT#237679004 "Status post (contextual qualifier) (qualifier value)" * code.coding[+] = $SCT#112231000 "Atypical (qualifier value) " * code.coding[+] = $SCT#174430004 "Resection of segment of liver (procedure)" * valueCodeableConcept.coding[+] = $SCT#94381002 "Metastatic malignant neoplasm to liver (disorder)" * valueCodeableConcept.coding[+] = $SCT#41647002 "No evidence of (contextual qualifier) (qualifier value)" * valueCodeableConcept.text = "Darüberhinaus kein Hinweis auf Leberfilialisierung." * bodySite = $SCT#181268008 "Entire liver" Instance: PatientKimMusterperson-Observation-11 InstanceOf: Observation Usage: #example Description: "kein Aszites" * partOf = Reference(PatientKimMusterperson-Procedure-3) * status = #final * code.coding = $SCT#389026000 "Acites" * valueCodeableConcept.coding = $SCT#860638000 "No ascites" * valueCodeableConcept.text = "kein Aszites" Instance: PatientKimMusterperson-Observation-12 InstanceOf: Observation Usage: #example Description: "kein Hinweis auf Lokalrezidiv" * partOf = Reference(PatientKimMusterperson-Procedure-3) * status = #final * code.coding = $SCT#255227004 "Recurrent" * valueCodeableConcept.coding = $SCT#41647002 "No evidence of (contextual qualifier) (qualifier value)" * valueCodeableConcept.text = "kein Hinweis auf Lokalrezidiv" Instance: PatientKimMusterperson-Observation-13 InstanceOf: Observation Usage: #example Description: "regrediente Milchglasinfiltrate im linken Oberlappen, somit a.e. atypisch entzündlich." * partOf = Reference(PatientKimMusterperson-Procedure-3) * status = #final * code.coding[+] = $SCT#255227004 "Recurrent" * code.coding[+] = $SCT#1217294009 "Ground glass opacity" * code.coding[+] = $SCT#44714003 "Structure of upper lobe of left lung" * code.text = "regrediente Milchglasinfiltrate im linken Oberlappen" * valueCodeableConcept.coding[+] = $SCT#112231000 "Atypical" * valueCodeableConcept.coding[+] = $SCT#257552002 "Inflammation" * valueCodeableConcept.text = "a.e. atypisch entzündlich" Instance: PatientKimMusterperson-Observation-14 InstanceOf: Observation Usage: #example Description: "Leicht vermehrter mediastinaler Lymphknotenbesatz ohne Kontrastmittelaufnahme" * partOf = Reference(PatientKimMusterperson-Procedure-3) * status = #final * code.coding = $SCT#245276004 "Mediastinal lymph node group" * code.text = "mediastinaler Lymphknoten" * valueCodeableConcept.coding[+] = $SCT#258283002 "Lymphomatous nodal involvement" * valueCodeableConcept.coding[+] = $SCT#373067005 "No" * valueCodeableConcept.coding[+] = $SCT#385420005 "Contrast media" * valueCodeableConcept.coding[+] = $SCT#151174005 "Drug intake observed" * valueCodeableConcept.text = "vermehrter mediastinaler Lymphknotenbesatz ohne Kontrastmittelaufnahme" Instance: PatientKimMusterperson-Observation-15 InstanceOf: Observation Usage: #example Description: "Leicht vermehrter mediastinaler Lymphknotenbesatz ohne pathologische Vergrößerung, Verlaufskontrolle empfohlen" * partOf = Reference(PatientKimMusterperson-Procedure-3) * status = #final * code.coding = $SCT#245276004 "Mediastinal lymph node group" * code.text = "mediastinaler Lymphknoten" * valueCodeableConcept.coding[+] = $SCT#373067005 "No" * valueCodeableConcept.coding[+] = $SCT#15454001 "Increased Size" * valueCodeableConcept.text = "ohne pathologische Vergrößerung" // 19.12.22 CT T/A // - [ ] progredienter Aszites (ca. 700ml), Peritonealblatt mit zunehmender, unregelmäßiger KM-Aufnahme, suspekt auf Progress der bekannten Peritonealkarzinose. V.a. Lokalrezidiv bei kontrastmittelaufnehmender Raumforderung im kleinen Becken // - [ ] KM-affine Vermehrung sowie pathologische Vergrößerung mehrerer mediastinaler Lymphknoten suspekt auf lymphonodale Metastasierung Instance: PatientKimMusterperson-Procedure-4 InstanceOf: MII_PR_Prozedur_Procedure Usage: #example Description: "19.12.22 CT T/A" * status = #completed * subject = Reference(PatientKimMusterperson) * code.coding = $OPS#3-20 "Native Computertomographie" * performedDateTime = 2022-12-19 * bodySite[+] = $SCT#4120138 "Abdomen" * bodySite[+] = $SCT#37542245 "Thorax" Instance: PatientKimMusterperson-Observation-16 InstanceOf: Observation Usage: #example Description: "progredienter Aszites (ca. 700ml)" * partOf = Reference(PatientKimMusterperson-Procedure-4) * status = #final * code.coding = $SCT#389026000 "Acites" * code.coding = $SCT#255314001 "Progressive" * code.text = "Progredienter Aszites" * valueQuantity.value = 700 * valueQuantity.unit = "ml" * valueQuantity.code = $SCT#258773002 "mL" Instance: PatientKimMusterperson-Observation-17 InstanceOf: Observation Usage: #example Description: "Peritonealblatt mit zunehmender, unregelmäßiger KM-Aufnahme" * partOf = Reference(PatientKimMusterperson-Procedure-4) * status = #final * code.coding = $SCT#362700006 "Entire peritoneal serous membrane of peritoneum" * code.text = "Peritonealblatt" * valueCodeableConcept.coding[+] = $SCT#385420005 "Contrast media" * valueCodeableConcept.coding[+] = $SCT#49608001 "Irregular" * valueCodeableConcept.coding[+] = $SCT#260366006 "Increase" * valueCodeableConcept.coding[+] = $SCT#151174005 "Drug intake observed" * valueCodeableConcept.text = "Peritonealblatt mit zunehmender, unregelmäßiger KM-Aufnahme" Instance: PatientKimMusterperson-Observation-18 InstanceOf: Observation Usage: #example Description: "suspekt auf Progress der bekannten Peritonealkarzinose" * partOf = Reference(PatientKimMusterperson-Procedure-4) * status = #final * code.coding = $SCT#836274002 "Carcinomatosis of peritoneum" * code.text = "Peritonealkarzinose" * valueCodeableConcept.coding = $SCT#255314001 "Progressive" * valueCodeableConcept.text = "Progress" Instance: PatientKimMusterperson-Observation-19 InstanceOf: Observation Usage: #example Description: "V.a. Lokalrezidiv bei kontrastmittelaufnehmender Raumforderung im kleinen Becken" * partOf = Reference(PatientKimMusterperson-Procedure-4) * status = #final * code.coding = $SCT#80266002 "True pelvis" * code.text = "kleinen Becken" * valueCodeableConcept.coding = $SCT#255227004 "Recurrent" * valueCodeableConcept.text = "Lokalrezidiv bei kontrastmittelaufnehmender Raumforderung" // 20.03.2023 CT T/A: // - [x] regredienter Aszites, rückläufige KM-Aufnahme der lokalrezidivsuspekten Raumforderung im kleinen Becken // - [x] noch flaue, aber insgesamt regrediente KM-Aufnhame der zahlenmäßig vermehrten LK im Mediastinum // - [x] keine neue metastasensuspekte Läsion Instance: PatientKimMusterperson-Procedure-5 InstanceOf: MII_PR_Prozedur_Procedure Usage: #example Description: "20.03.2023 CT T/A" * status = #completed * subject = Reference(PatientKimMusterperson) * code.coding = $OPS#3-20 "Native Computertomographie" * performedDateTime = 2023-03-20 * bodySite[+] = $SCT#4120138 "Abdomen" * bodySite[+] = $SCT#37542245 "Thorax" Instance: PatientKimMusterperson-Observation-20 InstanceOf: Observation Usage: #example Description: "regredienter Aszites" * partOf = Reference(PatientKimMusterperson-Procedure-5) * status = #final * code.coding = $SCT#389026000 "Acites" * code.text = "Aszites" * valueCodeableConcept.coding = $SCT#37865006 "Regressive" * valueCodeableConcept.text = "Regredient" Instance: PatientKimMusterperson-Observation-21 InstanceOf: Observation Usage: #example Description: "rückläufige KM-Aufnahme der lokalrezidivsuspekten Raumforderung im kleinen Becken" * partOf = Reference(PatientKimMusterperson-Procedure-5) * status = #final * code.coding = $SCT#80266002 "True pelvis" * code.text = "im kleinen Becken" * valueCodeableConcept.coding[+] = $SCT#37865006 "Regressive" * valueCodeableConcept.coding[+] = $SCT#385420005 "Contrast media" * valueCodeableConcept.text = "rückläufige KM-Aufnahme der lokalrezidivsuspekten Raumforderung" Instance: PatientKimMusterperson-Observation-22 InstanceOf: Observation Usage: #example Description: "noch flaue, aber insgesamt regrediente KM-Aufnhame der zahlenmäßig vermehrten LK im Mediastinum" * partOf = Reference(PatientKimMusterperson-Procedure-5) * status = #final * code.coding = $SCT#274744005 "Localized enlarged lymph nodes" * code.text = "zahlenmäßig vermehrten LK im Mediastinum" * valueCodeableConcept.coding[+] = $SCT#37865006 "Regressive" * valueCodeableConcept.coding[+] = $SCT#385420005 "Contrast media" * valueCodeableConcept.text = "noch flaue, aber insgesamt regrediente KM-Aufnhame" Instance: PatientKimMusterperson-Observation-23 InstanceOf: Observation Usage: #example Description: "keine neue metastasensuspekte Läsion" * partOf = Reference(PatientKimMusterperson-Procedure-5) * status = #final * code.coding = $SCT#52988006 "Lesion" * code.text = "Läsion" * valueCodeableConcept.coding = $SCT#373067005 "No" * valueCodeableConcept.text = "keine neue" // 20.08.2023 CT T/A: // - [x] kein Aszites, fast vollständig regredientes Lokalrezidiv ohne KM-Aufnahme im kleinen Becken Instance: PatientKimMusterperson-Procedure-6 InstanceOf: MII_PR_Prozedur_Procedure Usage: #example Description: "20.08.2023 CT T/A" * status = #completed * subject = Reference(PatientKimMusterperson) * code.coding = $OPS#3-20 "Native Computertomographie" * performedDateTime = 2023-08-20 * bodySite[+] = $SCT#4120138 "Abdomen" * bodySite[+] = $SCT#37542245 "Thorax" Instance: PatientKimMusterperson-Observation-24 InstanceOf: Observation Usage: #example Description: "kein Aszites" * partOf = Reference(PatientKimMusterperson-Procedure-6) * status = #final * code.coding = $SCT#389026000 "Acites" * valueCodeableConcept.coding = $SCT#860638000 "No ascites" * valueCodeableConcept.text = "kein Aszites" Instance: PatientKimMusterperson-Observation-25 InstanceOf: Observation Usage: #example Description: "fast vollständig regredientes Lokalrezidiv ohne KM-Aufnahme im kleinen Becken" * partOf = Reference(PatientKimMusterperson-Procedure-6) * status = #final * code.coding = $SCT#255227004 "Recurrent" * code.text = "Lokalrezidiv" * valueCodeableConcept.coding[+] = $SCT#37865006 "Regressive" * valueCodeableConcept.coding[+] = $SCT#373067005 "No" * valueCodeableConcept.coding[+] = $SCT#385420005 "Contrast media" * valueCodeableConcept.coding[+] = $SCT#151174005 "Drug intake observed" * valueCodeableConcept.text = "regredientes Lokalrezidiv ohne KM-Aufnahme im kleinen Becken" // 22.10.2023 CT T/A // - [x] lediglich geringer Aszites im kleinen Becken, vormals KM-aufnehmendes Lokalrezidiv im kleinen Becken aktuell metrisch nur noch schwer fassbar // - [x] formal noch vermehrte, jedoch nicht mehr KM-aufnehmende mediastinale Lymphknoten Instance: PatientKimMusterperson-Procedure-7 InstanceOf: MII_PR_Prozedur_Procedure Usage: #example Description: "22.10.2023 CT T/A" * status = #completed * subject = Reference(PatientKimMusterperson) * code.coding = $OPS#3-20 "Native Computertomographie" * performedDateTime = 2023-10-22 * bodySite[+] = $SCT#4120138 "Abdomen" * bodySite[+] = $SCT#37542245 "Thorax" Instance: PatientKimMusterperson-Observation-26 InstanceOf: Observation Usage: #example Description: "geringer Aszites im kleinen Becken" * partOf = Reference(PatientKimMusterperson-Procedure-7) * status = #final * code.coding = $SCT#80266002 "True pelvis" * code.text = "kleinen Becken" * valueCodeableConcept.coding[+] = $SCT#255606000 "Minor" * valueCodeableConcept.coding[+] = $SCT#389026000 "Acites" * valueCodeableConcept.text = "geringer Aszites" Instance: PatientKimMusterperson-Observation-27 InstanceOf: Observation Usage: #example Description: "vormals KM-aufnehmendes Lokalrezidiv im kleinen Becken aktuell metrisch nur noch schwer fassbar" * partOf = Reference(PatientKimMusterperson-Procedure-7) * status = #final * code.coding[+] = $SCT#237679004 "Status post (contextual qualifier) (qualifier value)" * code.coding[+] = $SCT#246455001 "Recurrence" * code.text = "vormals KM-aufnehmendes Lokalrezidiv im kleinen Becken" * valueCodeableConcept.coding[+] = $SCT#246455001 "Recurrence" * valueCodeableConcept.coding[+] = $SCT#263920009 "Unrecordable" * valueCodeableConcept.text = "aktuell metrisch nur noch schwer fassbar" * bodySite.coding = $SCT#80266002 "True pelvis" Instance: PatientKimMusterperson-Observation-29 InstanceOf: Observation Usage: #example Description: "formal noch vermehrte mediastinale Lymphknoten" * partOf = Reference(PatientKimMusterperson-Procedure-7) * status = #final * code.coding = $SCT#245276004 "Mediastinal lymph node group" * code.text = "mediastinale Lymphknoten" * valueCodeableConcept.coding = $SCT#35105006 "Increased" * valueCodeableConcept.text = "formal noch vermehrte" Instance: PatientKimMusterperson-Observation-30 InstanceOf: Observation Usage: #example Description: "nicht mehr KM-aufnehmende mediastinale Lymphknoten" * partOf = Reference(PatientKimMusterperson-Procedure-7) * status = #final * code.coding = $SCT#245276004 "Mediastinal lymph node group" * code.text = "mediastinale Lymphknoten" * valueCodeableConcept.coding[+] = $SCT#373067005 "No" * valueCodeableConcept.coding[+] = $SCT#385420005 "Contrast media" * valueCodeableConcept.coding[+] = $SCT#151174005 "Drug intake observed" * valueCodeableConcept.text = "nicht mehr KM-aufnehmende"