TEMPLATE Radiologische Befunde - Pankreaskarzinom, Cholangiokarzinom (Radiologische Befunde - Pankreaskarzinom, Cholangiokarzinom)

TEMPLATE IDRadiologische Befunde - Pankreaskarzinom, Cholangiokarzinom
ConceptRadiologische Befunde - Pankreaskarzinom, Cholangiokarzinom
DescriptionZur Dokumentation von Ergebnissen und Interpretationen einer bildgebenden Untersuchung oder einer Reihe von durchgeführten bildgebenden Untersuchungen, die bei einem Patienten mit Pankreaskarzinom oder Cholangiokarzinom durchgeführt wurden.
PurposeZur Dokumentation von Ergebnissen und Interpretationen einer bildgebenden Untersuchung oder einer Reihe von durchgeführten bildgebenden Untersuchungen, die bei einem Patienten mit Pankreaskarzinom oder Cholangiokarzinom durchgeführt wurden.
References
Authorsdate: 2019-09-10; name: Samer Abboud Alkarkoukly; organisation: Uniklinikum Köln; email: mabbouda@uni-koeln.de
Other Details Languagedate: 2019-09-10; name: Samer Abboud Alkarkoukly; organisation: Uniklinikum Köln; email: mabbouda@uni-koeln.de
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, PARENT:MD5-CAM-1.0.1=55DB2D45BC470E831EE8C905348471E4, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=5b773819d69bfa00bfa01a90a2051b79, build_uid=0c80c276-ecf5-4634-8c81-20008f20ecd3}
KeywordsPankreaskarzinom; Cholangiokarzinom; Bildgebung; Diagnostik; Bildgebendes Verfahren; Bildgebende Diagnostik; bildgebend; Untersuchung; Ergebnis; Untersuchungsergebnis
Language useden
Citeable Identifier1246.169.342
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  • CT
  • MRT
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  • nativ
  • extrazelluläres KM
  • intrazelluläres KM
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  • Pankreas
  • Gallengang
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  • Pankreaskopf
  • Proc. uncinatus
  • Pankreaskorpus
  • Pankreasschwanz
  • Intrahepatisch (mit Angabe des/der Lebersegment(e))
  • Perihilär
  • Distal
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  • Lebersegment 1
  • Lebersegment 2
  • Lebersegment 3
  • Lebersegment 4
  • Lebersegment 4a
  • Lebersegment 4b
  • Lebersegment 4a/b
  • Lebersegment 5
  • Lebersegment 6
  • Lebersegment 7
  • Lebersegment 8
  • Lebersegmente 2/3
  • Lebersegmente 7/6
  • Lebersegmente 8/5
  • Lebersegmente 2/4a
  • Lebersegmente 3/4b
  • [...]
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  • Initialbefund
  • nach Neoadjuvanz
  • nach lokaler Therapie
  • unter systemischer Therapie
  • Verlaufskontrolle ohne Therapie
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  • Primärtumor vorhanden
  • kein Primärtumor
  • Primärtumor unklar
  • Lokalrezidiv vorhanden
  • kein Lokalrezidiv
  • Lokalrezidiv unklar
  • Fernmetastasen vorhanden
  • keine Fernmetastasen
  • Fernmetastasen unklar
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  • PUL
  • OSS
  • HEP
  • BRA
  • LYM
  • MAR
  • PLE
  • PER
  • ADR
  • SKI
  • OTH
  • missing
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  • TC (truncus coeliacus) - kein Kontakt
  • TC (truncus coeliacus) - Kontakt ≤ 180°
  • TC (truncus coeliacus) - Kontakt > 180°
  • LA (Leberarterie) - kein Kontakt
  • LA (Leberarterie) - Kontakt ≤ 180°
  • LA (Leberarterie) - Kontakt > 180°
  • AMS (Arteria mesenterica superior) - kein Kontakt
  • AMS (Arteria mesenterica superior) - Kontakt ≤ 180°
  • AMS (Arteria mesenterica superior) - Kontakt > 180°
  • VMS (Vena mesenterica superia) - kein Kontakt
  • VMS (Vena mesenterica superia) - Kontakt ≤ 180°
  • VMS (Vena mesenterica superia) - Kontakt > 180°
  • PA (inkl. PA-Thrombose) - kein Kontakt
  • PA (inkl. PA-Thrombose) - Kontakt ≤ 180°
  • PA (inkl. PA-Thrombose) - Kontakt > 180°
  • [...]
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  • ja
  • nein
  • unklar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result_progress_evaluation.v1], code=at0000, itemType=CLUSTER, level=5, text=Verlaufsbeurteilung der Bildgebung, description=Beurteilung des Verlaufs des radiologischen Musters für ein bestimmtes Problem oder eine Diagnose eines Patienten zu einem bestimmten Zeitpunkt in der Relation zum einem der vorausgegangenen bildgebenden Untersuchungsergebnissen., comment=Zum Beispiel die Veränderungen der Größe eines diagnostizierten Primärtumors werden in einer Verlaufskontrolle im Vergleich zu dem Initialbefund beurteilt., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result_progress_evaluation.v1]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Beurteilung der Änderung, description=Die Änderung erfolgte im radiologischen Bild im Vergleich zum vorherigen Bild., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Befundkonstanz  [*]
  • Befundverbesserung  [*]
  • Befundverschlechterung  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result_progress_evaluation.v1]/items[at0015], code=at0015, itemType=ELEMENT, level=6, text=Beschreibung der Änderung, description=Wenn weitere Details zu melden sind, stellt dies eine kurze Beschreibung des geänderten radiologischen Musters oder Kommentare dar., comment=z.B. Bildung von Metastasen, oder Tumorvergrößerung oder Bildung einer Pfortaderthrombose etc., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/state[at0047], code=at0047, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/state[at0047]/items[at0048], code=at0048, itemType=ELEMENT, level=5, text=Diagnostische Qualität, description=Narrative description of factors, not recorded elsewhere, that may influence the test result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • ausreichend
  • eingeschränkt
  • nicht diagnostisch
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025], code=at0025, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027], code=at0027, itemType=CLUSTER, level=3, text=Details zur Bildstudie (DICOM Studie), description=Details concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0032], code=at0032, itemType=ELEMENT, level=4, text=DICOM study identifier, description=Unique identifier of this study allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0033], code=at0033, itemType=ELEMENT, level=4, text=Maßnahmen-ID, description=The local identifier given to the imaging examination report., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034], code=at0034, itemType=CLUSTER, level=4, text=Details zur Bildserie (DICOM Serie), description=Images referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034]/items[at0036], code=at0036, itemType=ELEMENT, level=5, text=DICOM series identifier, description=Unique identifier of this series allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034]/items[at0039], code=at0039, itemType=ELEMENT, level=5, text=Image DateTime, description=Specific date/time the imaging examination was performed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging.v0], code=at0000, itemType=CLUSTER, level=3, text=Imaging details, description=Details of imaging, used in requests for imaging, records of imaging procedures and imaging reports., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Untersuchungsprotokoll, description=The type of imaging., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Native Phase
  • Spätarterielle Phase
  • Venöse Phase
  • Spätvenöse Phase
  • T1 mit chemical Shift Imaging (in-opp-Phase /Dixon) axial
  • T1 GRE fettsupprimiert nativ axial
  • T1 GRE fettsupprimiert spätarteriell axial
  • T1 GRE fettsupprimiert venös axial
  • T1 GRE fettsupprimiert spätvenös axial
  • T1 GRE fettsupprimiert hepatobiliär axial
  • T2 axial
  • T2 koronar
  • Diffusionswichtung b=0-100 s/mm2
  • Diffusionswichtung b=500-1000 s/mm2
, extendedValues=null]], templateType=normal]