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Narrative

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Source1

{
  "resourceType": "ClinicalImpression",
  "id": "mii-exa-seltene-clinical-impression-erstvorstellung",
  "meta": {
    "profile": [
      "https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/StructureDefinition/mii-pr-seltene-clinical-impression|2027.0.0-ballot"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "status": "completed",
  "subject": {
    "reference": "Patient/mii-exa-seltene-patient-sma-001"
  },
  "encounter": {
    "reference": "Encounter/mii-exa-seltene-encounter-ambulant-001"
  },
  "effectiveDateTime": "2024-07-22",
  "date": "2024-07-22",
  "problem": [
    {
      "reference": "Condition/mii-exa-seltene-condition-sma-suspected"
    }
  ],
  "investigation": [
    {
      "code": {
        "text": "Familienanamnese"
      },
      "item": [
        {
          "reference": "FamilyMemberHistory/mii-exa-seltene-family-history-001"
        }
      ]
    },
    {
      "code": {
        "text": "Labordiagnostik"
      },
      "item": [
        {
          "reference": "Observation/mii-exa-seltene-observation-troponin-001"
        }
      ]
    }
  ],
  "summary": "Neugeborenes mit V.a. SMA aus Neugeborenenscreening. Familienanamnese zeigt unklare Muskelerkrankung der Urgroßmutter. Troponin T bereits erhöht (92 ng/l).",
  "finding": [
    {
      "itemReference": {
        "reference": "Condition/mii-exa-seltene-condition-sma-clinical"
      }
    },
    {
      "itemReference": {
        "reference": "Condition/mii-exa-seltene-condition-sma-genetic"
      }
    },
    {
      "itemCodeableConcept": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "1363512008",
            "display": "Troponin above reference range"
          }
        ]
      },
      "itemReference": {
        "reference": "Observation/mii-exa-seltene-observation-troponin-001"
      }
    }
  ],
  "prognosisCodeableConcept": [
    {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "67334001",
          "display": "Guarded prognosis"
        }
      ]
    }
  ],
  "note": [
    {
      "text": "Klinische Untersuchung gemäß SMA-Diagnoseprotokoll. Blutentnahme für Genetik veranlasst."
    },
    {
      "text": "Klinisches Bild vereinbar mit SMA Typ 1. Molekulargenetische Bestätigung ausstehend. Eltern über Therapieoptionen informiert."
    }
  ]
}