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Narrative

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Source1

{
  "resourceType": "ClinicalImpression",
  "id": "mii-exa-seltene-clinical-impression-nachsorge",
  "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-nachsorge-001"
  },
  "effectiveDateTime": "2024-08-12",
  "date": "2024-08-12",
  "previous": {
    "reference": "ClinicalImpression/mii-exa-seltene-clinical-impression-erstvorstellung"
  },
  "problem": [
    {
      "reference": "Condition/mii-exa-seltene-condition-sma-clinical"
    },
    {
      "reference": "Condition/mii-exa-seltene-condition-sma-genetic"
    }
  ],
  "summary": "Erste Nachsorge 14 Tage nach Gentherapie. Klinisch stabil. Troponin T weiter erhöht (106 ng/l), war jedoch bereits prätherapeutisch erhöht.",
  "finding": [
    {
      "itemCodeableConcept": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "1363512008",
            "display": "Troponin above reference range"
          }
        ]
      },
      "itemReference": {
        "reference": "Observation/mii-exa-seltene-observation-troponin-004"
      },
      "basis": "Troponin-Verlauf: 22.07: 92 ng/l, 28.07: 58 ng/l, 01.08: 57 ng/l, 12.08: 106 ng/l"
    },
    {
      "itemCodeableConcept": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "166645004",
            "display": "Alanine aminotransferase level within reference range"
          }
        ]
      },
      "basis": "ALT normwertig"
    },
    {
      "itemCodeableConcept": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "166667003",
            "display": "Aspartate aminotransferase/serum glutamic oxaloacetic transaminase level within reference range"
          }
        ]
      },
      "basis": "AST normwertig"
    },
    {
      "itemCodeableConcept": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "165555003",
            "display": "Platelet count normal"
          }
        ]
      },
      "basis": "Thrombozytenzahl normwertig"
    }
  ],
  "prognosisCodeableConcept": [
    {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "67334001",
          "display": "Guarded prognosis"
        }
      ]
    }
  ],
  "note": [
    {
      "text": "Standardisierte Nachsorgeuntersuchung nach Gentherapie gemäß Zentrumsprotokoll"
    },
    {
      "text": "Troponin-Erhöhung präexistent, nicht therapieassoziiert. Gentherapie gut vertragen. Weiterführung der Prednisolon-Therapie. Nächste Kontrolle in 4 Wochen."
    }
  ]
}