醫療影像及報告實作指引
0.1.0 - DSTU0 ci-build
醫療影像及報告實作指引 - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Generated Narrative: DiagnosticReport DiagnosticReportLC
| Subject | No display for Patient |
| Reported | 2021-06-23 14:35:32+0000 |
| Performer | Practitioner 大吉 連 (official) |
| Identifier | https://www.vghtpe.gov.tw//123456 |
Report Details
| Code | Value | Flags | When For |
| Pathology report gross observation Narrative | The specimen received in formalin has 3 parts. Part (A) consists of a piece of lung, labeled RLL segment and measures 6.5 x 3.3 x1.8 cm. A gray white firm tumor, 1.2 x 0.5 x 0.5 cm, is noted 0.8 cm from the bronchial cut end, 0.1 cm from visceral pleura.Part (B) consists of groups of lymph nodes labeled as above.Part (C) is a piece of lung labeled 'RLL margin', measuring 3.8x 1.8 x 1 cm. Representative parts are taken for sections in 5 blocks. (A:bronchial and vascular cut end, B:stapled margin,C:tumor, D:specimen labeled 'RLL margin', E:interlobar LNs)(WKW) | Final | 2021-06-21 |
| Histology type in Cancer specimen Narrative | adenocarcinoma,acinar predominant | Final | 2021-06-21 |
| Pattern (attribute) | acinar(90%),lepidic(10%) | Final | 2021-06-21 |
| Cell type in Specimen | non-mucinous tumor cells | Final | 2021-06-21 |
| Surgical margins cancer involvement | free of tumor involvement | Final | 2021-06-21 |
| Structure of parenchyma of lung (body structure) | congestion | Final | 2021-06-21 |
| Size Tumor | 0.6x0.4cm | Final | 2021-06-21 |
| Deepest extent of invasion [Type] in Specimen | 0.6 cm (Details: UCUM codecm = 'cm') | Final | 2021-06-21 |
| Lymph-vascular invasion Cancer specimen | absent | Final | 2021-06-21 |
| Perineural invasion [Presence] in Cancer specimen | absent | Final | 2021-06-21 |
| Pleural invasion | absent(PL0) | Final | 2021-06-21 |
| Spread Through Air Spaces(STAS) | absent | Final | 2021-06-21 |
| Tumor necrosis (morphologic abnormality) | absent | Final | 2021-06-21 |
| Primary tumor.pathology Cancer | tumor <=1 cm or less in greatest dimension(pT1a) | Final | 2021-06-21 |
| Regional lymph nodes.pathology [Class] Cancer | all without metastatic tumor(pN0) | Final | 2021-06-21 |
| Distant metastases.pathology [Class] Cancer | Error: unknown | Final | 2021-06-21 |
| Stage group.other Cancer | pT1aN0 | Final | 2021-06-21 |
| World Health Organization tumor classification (observable entity) | Grade group 2 (microscopic measurement) | Final | 2021-06-21 |
| Ancillary studies | Tumor cell positive for TTF-1 and negative for p40;Multinucleate giant cell negative for CK | Final | 2021-06-21 |
Adenocarcinoma, acinar predominant, pT1aN0