| ARCHETYPE ID | openEHR-EHR-CLUSTER.imaging_exam-lesion-adnexal_mass.v0 |
|---|---|
| Concept | Imaging examination of an adnexal mass |
| Description | Findings on radiological examination of an adnexal mass identified in the pelvis, usually related to a single ovary and/or fallopian tube and associated connective tissues. |
| Use | Use to record the findings on radiological examination of a single adnexal mass. The intent of this archetype is to describe the key attributes which would support a determination of the risk of an adnexal mass being malignant. This archetype has been specifically designed to be used in the 'Additional details' SLOT within any of the CLUSTER.imaging_exam family of archetypes which will provide the context for the adnexal mass, for example CLUSTER.imaging_exam-pelvis, CLUSTER.imaging_exam-ovary, or the CLUSTER.imaging_exam-fallopian_tube archetypes, but can also be used within other ENTRY or CLUSTER archetypes where clinically appropriate. If there is more than one adnexal mass within the context of the same body structure or region, use a separate instance of this archetype to describe each mass. |
| Misuse | Not to be used to record findings for a specified body structure or region. Use other archetypes from the CLUSTER.imaging_exam family for this purpose. Not to be used to record details related to the overall findings, context or technical details related to a complete imaging examination test result. Use the OBSERVATION.imaging_exam_result for this purpose. For example, comments on the study quality, differential diagnoses, and overall impression. |
| Purpose | To record the findings on radiological examination of a single adnexal mass. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2021-11-24 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2021-11-24 |
| Other Details (Language Independent) |
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| Keywords | abnormality, lesion, mass, tumour, tumor, nodule, cyst, ovary, fallopian |
| Lifecycle | in_development |
| UID | c48fbeda-df84-47b2-be2c-cff4bbdedf7e |
| Language used | en |
| Citeable Identifier | 1246.145.2658 |
| Revision Number | 0.0.1-alpha |
| items | |
| Body structure | Body structure: Identification of the body structure or region examined.
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| Body site | Body site: Identification of the area of the body under examination. For example: a lymph node group (body structure) which found in the 'Right axilla'. Coding of 'Body site' with a terminology, such as SNOMED CT, is desirable. If the body site has been fully identified in the 'Body structure' data element, this data element becomes redundant. |
| Structured body site | Structured body site: Structured details about the area of the body under examination. For example: details about a relative anatomical location, such as '2cm distal to the appendix'. If the body site has been fully identified in the 'Body structure' or 'Body site' data elements, then this SLOT becomes redundant. Include: openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ |
| Imaging findings | Imaging findings: Narrative description of the imaging findings observed during this examination. |
| Additional details | Additional details: Additional structured details about imaging findings for the identified body structure or region, or findings of related structures. Include: openEHR-EHR-CLUSTER.imaging_ openEHR-EHR-CLUSTER.imaging_ openEHR-EHR-CLUSTER.imaging_ |
| Impression | Impression: Single word, phrase or brief description that represents the clinical meaning and significance of all imaging findings for the identified body structure. Also referred to as 'Interpretation' or 'Opinion'. For example: 'No abnormality detected' or 'Free fluid present'. Coding of the 'Impression' with a terminology is permitted, if useful. Multiple occurrences allow for more than one coded impression. A narrative description may include a comparison with previous studies of the identified body structure, if appropriate. |
| Comment | Comment: Additional narrative about the imaging findings of the body structure, not captured in other fields. |
| Label | Label: A label for the lesion. Use to differentiate one lesion from another when there is more than one present within the context of the same body structure or region. |
| Type | Type: The type of mass. For example: Unilocular cyst (A unilocular cyst without septa, solid parts or papillary structures); Unilocular-solid cyst (A unilocular cyst with a measurable solid component or at least one papillary structure); Multilocular cyst (A cyst with at least one septum but no measurable solid components or papillary projections); Multilocular-solid cyst (A cyst with at least one septum and a measurable solid component or at least one papillary projection); Solid tumour (A tumor where the solid components comprise 80% or more of the tumour when assessed in a two-dimensional section); and Indeterminate (It is not possible to determine the type of mass). |
| Diameter | Diameter: A measured diameter of the lesion. This data element has 3 occurrences to allow for 3 measurements in different axes. Property: Length Units:
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| Shape | Shape: The shape of the lesion. |
| Texture | Texture: The texture of the lesion. |
| Definition | Definition: The definition of the lesion. For example: 'Well-defined' (The lesion is well-defined); and 'Poorly-defined' (The lesion is poorly-defined). |
| Contour | Contour: The contour of the lesion. |
| Margin | Margin: The margin of the lesion. |
| Calcification | Calcification: Presence of calcification in the lesion.
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| Effect | Effect: Narrative description about the effect of the lesion on surrounding structures. For example: presence of an echo shadow behind the lesion or that it is distorting adjacent structures. |
| Vascularisation | Vascularisation: Assessment of the blood flow to the lesion. For example: Doppler score 0/None; Doppler score 1/ Mild; Doppler score 2/Moderate; or Doppler score 3/Marked. |
| Vascularisation description | Vascularisation description: Narrative descripiton about the blood flow to the lesion. |
| Solid diameter | Solid diameter: A measured diameter of the largest solid tissue component. This data element has 3 occurrences to allow for 3 measurements in different axes. Property: Length Units:
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| Number of cyst locules | Number of cyst locules: The number of cyst locules in the adnexal mass. min: >=0 |
| Number of papillary projections | Number of papillary projections: The number of papillary projections in the adnexal mass. min: >=0 |
| Maximal septum thickness | Maximal septum thickness: The measured width of the thickest septum. Property: Length Units: >=0.0 mm Limit decimal places: 0 |
| Other contributors | Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor) Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India Peter Fedorcsak, University of Oslo, Norway (openEHR Editor) Heather Grain, Llewelyn Grain Informatics, Australia Evelyn Hovenga, EJSH Consulting, Australia Anjali Kulkarni, Karkinos, India Liv Laugen, Oslo University Hospital, Norway, Norway (openEHR Editor) Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Mikael Nyström, Cambio Healthcare Systems AB, Sweden Norwegian Review Summary, Norwegian Public Hospitals, Norway |
| Translators |
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