MII IG Kerndatensatz-Modul Seltene Erkrankungen
2027.0.0-ballot - Germany

This page is part of the MII Implementation Guide Seltene Erkrankungen (v2027.0.0-ballot: 2027 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

: Klinische Beurteilung - Nachsorge

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{
  "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"
    ]
  },
  "language" : "de",
  "text" : {
    "status" : "generated",
    "div" : "<div xml:lang=\"de\" lang=\"de\"><hr/><p><b>German</b></p><hr/><p class=\"res-header-id\"><b>Generated Narrative: ClinicalImpression mii-exa-seltene-clinical-impression-nachsorge</b></p><a name=\"de-mii-exa-seltene-clinical-impression-nachsorge\"> </a><a name=\"de-hcmii-exa-seltene-clinical-impression-nachsorge\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-mii-pr-seltene-clinical-impression.html\">MII Profile SE Clinical Impression</a> version: 2027.0.0-ballot</p></div><p><b>status</b>: Completed</p><p><b>subject</b>: <a href=\"Patient-mii-exa-seltene-patient-sma-001.html\">Anonymous Patient Female, DoB: 2024-07-01 ( https://www.medizininformatik-initiative.de/fhir/sid/patient-id#SMA-2024-001)</a></p><p><b>encounter</b>: <a href=\"Encounter-mii-exa-seltene-encounter-nachsorge-001.html\">Encounter: status = finished; class = ambulatory (ActCode#AMB); type = Follow-up encounter; period = 2024-08-12 --&gt; 2024-08-12</a></p><p><b>effective</b>: 2024-08-12</p><p><b>date</b>: 2024-08-12</p><p><b>previous</b>: <a href=\"ClinicalImpression-mii-exa-seltene-clinical-impression-erstvorstellung.html\">ClinicalImpression: status = completed; effective[x] = 2024-07-22; date = 2024-07-22; summary = Neugeborenes mit V.a. SMA aus Neugeborenenscreening. Familienanamnese zeigt unklare Muskelerkrankung der Urgroßmutter. Troponin T bereits erhöht (92 ng/l).; prognosisCodeableConcept = Guarded prognosis; note = Klinische Untersuchung gemäß SMA-Diagnoseprotokoll. Blutentnahme für Genetik veranlasst.,Klinisches Bild vereinbar mit SMA Typ 1. Molekulargenetische Bestätigung ausstehend. Eltern über Therapieoptionen informiert.</a></p><p><b>problem</b>: </p><ul><li><a href=\"Condition-mii-exa-seltene-condition-sma-clinical.html\">Condition Infantile spinale Muskelatrophie, Typ I [Typ Werdnig-Hoffmann]</a></li><li><a href=\"Condition-mii-exa-seltene-condition-sma-genetic.html\">Condition Spinal muscular atrophy, type I</a></li></ul><p><b>summary</b>: Erste Nachsorge 14 Tage nach Gentherapie. Klinisch stabil. Troponin T weiter erhöht (106 ng/l), war jedoch bereits prätherapeutisch erhöht.</p><blockquote><p><b>finding</b></p><p><b>itemCodeableConcept</b>: <span title=\"Codes:{http://snomed.info/sct 1363512008}\">Troponin above reference range</span></p><p><b>itemReference</b>: <a href=\"Observation-mii-exa-seltene-observation-troponin-004.html\">Observation Troponin T.cardiac [Mass/volume] in Serum or Plasma</a></p><p><b>basis</b>: Troponin-Verlauf: 22.07: 92 ng/l, 28.07: 58 ng/l, 01.08: 57 ng/l, 12.08: 106 ng/l</p></blockquote><blockquote><p><b>finding</b></p><p><b>itemCodeableConcept</b>: <span title=\"Codes:{http://snomed.info/sct 166645004}\">Alanine aminotransferase level within reference range</span></p><p><b>basis</b>: ALT normwertig</p></blockquote><blockquote><p><b>finding</b></p><p><b>itemCodeableConcept</b>: <span title=\"Codes:{http://snomed.info/sct 166667003}\">Aspartate aminotransferase/serum glutamic oxaloacetic transaminase level within reference range</span></p><p><b>basis</b>: AST normwertig</p></blockquote><blockquote><p><b>finding</b></p><p><b>itemCodeableConcept</b>: <span title=\"Codes:{http://snomed.info/sct 165555003}\">Platelet count normal</span></p><p><b>basis</b>: Thrombozytenzahl normwertig</p></blockquote><p><b>prognosisCodeableConcept</b>: <span title=\"Codes:{http://snomed.info/sct 67334001}\">Guarded prognosis</span></p><p><b>note</b>: , </p><blockquote><div><p>Standardisierte Nachsorgeuntersuchung nach Gentherapie gemäß Zentrumsprotokoll</p>\n</div></blockquote><blockquote><div><p>Troponin-Erhöhung präexistent, nicht therapieassoziiert. Gentherapie gut vertragen. Weiterführung der Prednisolon-Therapie. Nächste Kontrolle in 4 Wochen.</p>\n</div></blockquote></div>"
  },
  "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."
    }
  ]
}