{
  "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"]
  },
  "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-erstvorstellung</b></p><a name=\"de-mii-exa-seltene-clinical-impression-erstvorstellung\"> </a><a name=\"de-hcmii-exa-seltene-clinical-impression-erstvorstellung\"> </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-ambulant-001.html\">Encounter: status = finished; class = ambulatory (ActCode#AMB); type = Follow-up encounter; period = 2024-07-22 --&gt; 2024-07-22</a></p><p><b>effective</b>: 2024-07-22</p><p><b>date</b>: 2024-07-22</p><p><b>problem</b>: <a href=\"Condition-mii-exa-seltene-condition-sma-suspected.html\">Condition Werdnig-Hoffmann disease</a></p><blockquote><p><b>investigation</b></p><p><b>code</b>: <span title=\"Codes:\">Familienanamnese</span></p><p><b>item</b>: <a href=\"FamilyMemberHistory-mii-exa-seltene-family-history-001.html\">FamilyMemberHistory: extension = Unknown; status = completed; date = 2024-07-22; relationship = Great grandmother</a></p></blockquote><blockquote><p><b>investigation</b></p><p><b>code</b>: <span title=\"Codes:\">Labordiagnostik</span></p><p><b>item</b>: <a href=\"Observation-mii-exa-seltene-observation-troponin-001.html\">Observation Troponin T.cardiac [Mass/volume] in Serum or Plasma</a></p></blockquote><p><b>summary</b>: Neugeborenes mit V.a. SMA aus Neugeborenenscreening. Familienanamnese zeigt unklare Muskelerkrankung der Urgroßmutter. Troponin T bereits erhöht (92 ng/l).</p><blockquote><p><b>finding</b></p><p><b>itemReference</b>: <a href=\"Condition-mii-exa-seltene-condition-sma-clinical.html\">Condition Infantile spinale Muskelatrophie, Typ I [Typ Werdnig-Hoffmann]</a></p></blockquote><blockquote><p><b>finding</b></p><p><b>itemReference</b>: <a href=\"Condition-mii-exa-seltene-condition-sma-genetic.html\">Condition Spinal muscular atrophy, type I</a></p></blockquote><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-001.html\">Observation Troponin T.cardiac [Mass/volume] in Serum or Plasma</a></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>Klinische Untersuchung gemäß SMA-Diagnoseprotokoll. Blutentnahme für Genetik veranlasst.</p>\n</div></blockquote><blockquote><div><p>Klinisches Bild vereinbar mit SMA Typ 1. Molekulargenetische Bestätigung ausstehend. Eltern über Therapieoptionen informiert.</p>\n</div></blockquote></div>"
  },
  "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."
  }]
}