Generated Narrative: Composition r2bo-documento-biopsia-ex Profile: Perfil de la Cabecera del Documento de Biopsía Extensión De Referencia al Reporte: Diagnostic Report for 'Breast Pathology biopsy report' for '->Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))' identifier: r2bo-2020-0001 status: Final type: Informe de Biopsia de Mama category: Pathology (gross & histopath, not surgical) date: 2021-08-01 10:00:00-0400 author: PractitionerRole MÉDICO CIRUJANO title: Informe de Biopsia de Mama
Pathology (gross & histopath, not surgical)
Solicitud de Biopsia
Muestra de Biopsia
Macroscopia de Biopsia
Microscopia de Biopsia
Hallazgos de Biopsia
Conclusiones de Biopsia
Notas del Informe de Biopsia: Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral
Generated Narrative: ServiceRequest r2bo-solicitud-informe-apa-ej version: 2 Profile: Perfil de Solicitud de Informe de Anatomía Patológica identifier: 111111101 status: Completed intent: Order priority: Routine code: Informe de Biopsia subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) requester: PractitionerRole MÉDICO CIRUJANO performer: Organization Hospital Dr. Hernán Henríquez Aravena (Temuco) locationCode: hospital laboratory reasonCode: Neoplasm of uncertain behaviour of breast specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Generated Narrative: Patient paciente-requiere-examen Profile: MINSAL Paciente Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) Active: true Deceased: false Marital Status: Soltero(a) Other Id: RUN/16182522-0 (use: official, ) Contact Detail +56912387678 Avenida Las Torres 3456, Departamento 702 null null null (home) Sexo Biologico del paciente Femenina País de origen del paciente Uruguay Pueblos Originarios: pertenece: false Código de Países Chile Religión Ninguna, ateo, agnóstico Identidad De Género Femenina Pueblos Afrodescendiente false
Avenida Las Torres 3456, Departamento 702
Generated Narrative: PractitionerRole ProfesionalHospital Profile: Perfil de Rol Profesional practitioner: Practitioner Juan Perez organization: Organization Hospital Dr. Hernán Henríquez Aravena (Temuco) code: MÉDICO CIRUJANO location: Location Medicina General
Generated Narrative: PractitionerRole r2bo-anatopatologo-hospital Profile: Perfil de Rol Profesional practitioner: Practitioner Patricia Gutierrez organization: Organization Hospital Dr. Hernán Henríquez Aravena (Temuco) code: MÉDICO CIRUJANO specialty: ANATOMÍA PATOLÓGICA
Generated Narrative: Practitioner profesional-hospital-collector Profile: Prestador Profesional identifier: RUN/5135329-3 (use: official, ) name: Juan Perez birthDate: 1991-05-18 Qualifications - Identifier Code * cert MÉDICO CIRUJANO
Generated Narrative: Practitioner profesional-hospital-anatopatologo Profile: Prestador Profesional identifier: RUN/19283789-2 (use: official, ) name: Patricia Gutierrez gender: Female birthDate: 1983-11-18 qualification identifier: cert code: MÉDICO CIRUJANO qualification identifier: esp code: MEDICINA INTERNA qualification identifier: subesp code: ANATOMÍA PATOLÓGICA
Generated Narrative: Organization hospital-collector Profile: Prestador Institucional identifier: 121109 name: Hospital Dr. Hernán Henríquez Aravena (Temuco)
Hospital Dr. Hernán Henríquez Aravena (Temuco)
Generated Narrative: Specimen r2bo-specimen-example Profile: Perfil de Muestra identifier: 110101101 status: Available type: Tissue subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) receivedTime: 2021-06-01 00:00:00+0000 Collections - Collector Collected[x] Method BodySite * PractitionerRole MÉDICO CIRUJANO 2021-06-01 10:00:00+0000 Biopsy of breast Breast note: Resección completa de tejido mamario, posible carcinoma
Resección completa de tejido mamario, posible carcinoma
Generated Narrative: Observation r2bo-observacion-microscopica-ex Profile: Perfil de Observación Microscópica basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Pathology report microscopic observation in Specimen subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: Se observa tejido mamario con células epiteliales y estromales, con signos de malignidad con metastasis en ganglios linfáticos specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Se observa tejido mamario con células epiteliales y estromales, con signos de malignidad con metastasis en ganglios linfáticos
Generated Narrative: BodyStructure r2bo-tumor-ex Profile: Perfil de la Morfología y Topología del Tumor morphology: Carcinoma ductal infiltrante location: Mama patient: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
Generated Narrative: Observation r2bo-observacion-macroscopica-ex Profile: Perfil de Observación Macroscópica basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Macroscopic observation [Interpretation] in Specimen Narrative subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: Muestra de biopsia de tejido mamario, de 2x2x1 cm, de color blanco, consistencia firme, bordes irregulares, sin lesiones visibles a simple vista specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Muestra de biopsia de tejido mamario, de 2x2x1 cm, de color blanco, consistencia firme, bordes irregulares, sin lesiones visibles a simple vista
Generated Narrative: Observation r2bo-estadificacion-tnm-ex Profile: Perfil de Grupo Estadificación TNM basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Pathologic TNM stage grouping (observable entity) subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma hasMember: Observation pT category (observable entity) Observation Stage of tumour involvement of regional lymph nodes Observation Stage of distant metastasis of tumour
Generated Narrative: Observation r2bo-tnm-categoria-tumor-primario-ex Profile: Perfil de Categoria TNM Tumor Primario basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: pT category (observable entity) subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: American Joint Committee on Cancer pT2 (qualifier value) specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Generated Narrative: Observation r2bo-tnm-categoria-nodo-regional-ex Profile: Perfil de Categoria TNM Nodos Regional basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Stage of tumour involvement of regional lymph nodes subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: American Joint Committee on Cancer pN2 specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Generated Narrative: Observation r2bo-tnm-categoria-metastasis-distantel-ex Profile: Perfil de Categoria TNM de Metástasis Distante basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Stage of distant metastasis of tumour subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: American Joint Committee on Cancer pM1 (qualifier value) specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Generated Narrative: Observation r2bo-observacion-infiltracion-perineural-ex Profile: Perfil de Observación Infiltración Perineural basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Status of tumour perineural invasion subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: Perineural invasion by tumor not identified (finding) specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Generated Narrative: Observation r2bo-observacion-ganglios-linfaticos-ex Profile: Perfil de Observación Ganglios Linfáticos basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Lymph nodes with metastasis [#] in Cancer specimen subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: true specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma Components - Code Value[x] * Number (attribute) 4
Generated Narrative: Observation r2bo-observacion-infiltracion-peritumoral-ex Profile: Perfil de Observación Infiltración Peritumoral basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Status of peritumoral lymphocyte response (observable entity) subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: Marked peritumoral lymphocytic response specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Generated Narrative: Observation r2bo-observacion-invasion-linfatica-ex Profile: Perfil de Observación Invasión Linfatica basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Lymphatic.small vessel.invasion [Identifier] in Specimen by CAP cancer protocols subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: Present specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Generated Narrative: Observation r2bo-observacion-invasion-vascular-ex Profile: Perfil de Observación Invasión Vascular basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Venous.large vessel.invasion [Identifier] in Specimen by CAP cancer protocols subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: Present specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Generated Narrative: Observation r2bo-observacion-margen-quirurgico-ex Profile: Perfil de Observación Margen Quirúrgico basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Surgical margin observable (observable entity) subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: Deep margin specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma component code: Surgical margin site involved by tumour value: Positive component code: Distance of tumor from closest margin value: 1.5 Millimeter (Details: UCUM codemm = 'mm')
Generated Narrative: Observation r2bo-observacion-centricidad-ex Profile: Perfil de Observación Multicentricidad basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Multiple tumors reported as single primary Cancer subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: true specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma Components - Code Value[x] * Number (attribute) 2
Generated Narrative: Observation r2bo-observacion-multifocalidad-ex Profile: Perfil de Observación Focalidad basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Status of specimen involvement by multifocal invasion (observable entity) subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: true specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma Components - Code Value[x] * Number (attribute) 2
Generated Narrative: Observation r2bo-observacion-porcentaje-necrosis-ex Profile: Perfil de Observación Porcentaje Necrosis basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Percentage of tumour involved by necrosis subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: 5 % (Details: UCUM code% = '%') specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Generated Narrative: Observation r2bo-observacion-post-tratamiento-neoadjuvancia-ex Profile: Perfil de Observación Evaluación Post Neoadyuvancia basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Tumor response to neoadjuvant therapy subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO value: El tratamiento entregado no ha sido efectivo para reducir el tamaño del tumor, por lo que se recomienda un nuevo tratamiento. specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
El tratamiento entregado no ha sido efectivo para reducir el tamaño del tumor, por lo que se recomienda un nuevo tratamiento.
Generated Narrative: Observation r2bo-tamano-tumor-ex Profile: Perfil de Tamaño del Tumor basedOn: ServiceRequest Pathologist report status: Final category: Laboratory code: Size Tumor subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) effective: 2021-06-01 12:00:00-0400 performer: PractitionerRole MÉDICO CIRUJANO specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma component code: Size.maximum dimension in Tumor value: 1.5 cm (Details: UCUM codecm = 'cm') component code: Size additional dimension in Tumor value: 1.2 cm (Details: UCUM codecm = 'cm') component code: Size additional dimension in Tumor value: 0.7 cm (Details: UCUM codecm = 'cm')