# entry[].resource.text.div
CT Abdomen/Pelvis without Contrast

Status | PRELIMINARY
Conclusion | Diffuse thickening descending and sigmoid colon. Pericolonic stranding. Mild pneumatosis cannot be excluded. No free air. Limited evaluation of vasculature without contrast. Impression: Colitis, questionable ischemic changes in sigmoid, correlate clinically.

# entry[].resource.conclusion
Diffuse thickening descending and sigmoid colon. Pericolonic stranding. Mild pneumatosis cannot be excluded. No free air. Limited evaluation of vasculature without contrast. Impression: Colitis, questionable ischemic changes in sigmoid, correlate clinically.

# entry[].resource.text.div
rthrt

Status | FINAL
Conclusion | Moderate

# entry[].resource.presentedForm[].title
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# entry[].resource.text.div
CT Abdomen/Pelvis with IV Contrast

Status | PRELIMINARY
Conclusion | Moderate pneumoperitoneum. Free fluid in pelvis. Sigmoid colon with wall thickening and surrounding inflammatory changes. 2.5 cm pericolic abscess. Findings concerning for perforated sigmoid diverticulitis.

# entry[].resource.conclusion
Moderate pneumoperitoneum. Free fluid in pelvis. Sigmoid colon with wall thickening and surrounding inflammatory changes. 2.5 cm pericolic abscess. Findings concerning for perforated sigmoid diverticulitis.

# entry[].resource.text.div
Obleeee

Status | FINAL
Conclusion | Moderate

# entry[].resource.presentedForm[].title
;jdsjrg gg. dfkff fdf gneedg ege;g erg e eg ge eger

# entry[].resource.text.div
Nota di consulto

Status | REGISTERED
Conclusion | <div xmlns="http://www.w3.org/1999/xhtml"><p> [Questo paragrafo contiene una descrizione testuale delle conclusioni] </p></div>

Name | Value | Interpretation | Reference Range | Status
Motivo della visita | IPOGLICEMIA NON SPECIFICATA | | | FINAL
Storia Generale | | | | FINAL
ESAME MICROSCOPICO DI CAMPIONE DI SANGUE - PARASSITOLOGIA | [ESITO_ESAME] | | | FINAL
Osservazioni fisiche | | | | FINAL
<div xmlns="http://www.w3.org/1999/xhtml"><p> Azione cardiaca ritmica normo frequente. Rumore respiratorio fisiologico su tutto l’ambito. Crepiti fissi alla base destra. Addome trattabile alla palpazione superficiale e profonda. Modesti edemi declivi </p></div>
Confronto con Precedenti Esami Eseguiti | | | | FINAL
<div xmlns="http://www.w3.org/1999/xhtml"><p> [Descrizione del confronto con precedenti esami eseguiti] </p></div>
Referto | | | | FINAL
<div xmlns="http://www.w3.org/1999/xhtml"><p> [Questo paragrafo contiene una descrizione testuale del referto] </p></div>
Diagnosi | ALTERAZIONI DEL TEST RAPIDO DELLA GLICEMIA | | | FINAL
Raccomandazioni | | | | FINAL
<div xmlns="http://www.w3.org/1999/xhtml"><p> [Questo paragrafo contiene una descrizione testuale dei suggerimenti per il medico prescrittore] </p></div>
Glucose [Mass/volume] in Blood by Automated test strip | | | | FINAL

# entry[].resource.conclusion
[Questo paragrafo contiene una descrizione testuale delle conclusioni]

# entry[].resource.text.div
Laboratory report

Status | FINAL

Name | Value | Interpretation | Reference Range | Status
Heart rate | 70 bpm | | | FINAL
Heart rate | 72 bpm | | | FINAL
Heart rate | 74 bpm | | | FINAL
Heart rate | 76 bpm | | | FINAL
Heart rate | 78 bpm | | | FINAL
Heart rate | 80 bpm | | | FINAL
Heart rate | 82 bpm | | | FINAL
Heart rate | 84 bpm | | | FINAL
Heart rate | 86 bpm | | | FINAL
Heart rate | 88 bpm | | | FINAL
Body temperature | 36.5 °C | | | FINAL
Body temperature | 36.7 °C | | | FINAL
Body temperature | 36.9 °C | | | FINAL
Body temperature | 37.1 °C | | | FINAL
Body temperature | 37.3 °C | | | FINAL
Body temperature | 37.5 °C | | | FINAL
Body temperature | 37.7 °C | | | FINAL
Body temperature | 37.9 °C | | | FINAL
Body temperature | 38.1 °C | | | FINAL
Body temperature | 38.3 °C | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 99 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 98 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 97 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 96 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 95 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 94 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 93 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 92 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 91 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 90 % | | | FINAL

# entry[].resource.text.div
Laboratory report

Status | FINAL

Name | Value | Interpretation | Reference Range | Status
Heart rate | 71 bpm | | | FINAL
Heart rate | 73 bpm | | | FINAL
Heart rate | 75 bpm | | | FINAL
Heart rate | 74 bpm | | | FINAL
Heart rate | 79 bpm | | | FINAL
Heart rate | 81 bpm | | | FINAL
Heart rate | 83 bpm | | | FINAL
Heart rate | 82 bpm | | | FINAL
Heart rate | 87 bpm | | | FINAL
Heart rate | 89 bpm | | | FINAL
Body temperature | 36.4 °C | | | FINAL
Body temperature | 36.8 °C | | | FINAL
Body temperature | 37.0 °C | | | FINAL
Body temperature | 37.2 °C | | | FINAL
Body temperature | 37.4 °C | | | FINAL
Body temperature | 37.3 °C | | | FINAL
Body temperature | 37.6 °C | | | FINAL
Body temperature | 37.8 °C | | | FINAL
Body temperature | 38.0 °C | | | FINAL
Body temperature | 38.2 °C | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 98 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 97 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 96 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 95 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 94 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 93 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 92 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 91 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 90 % | | | FINAL
Oxygen saturation in Arterial blood by Pulse oximetry | 89 % | | | FINAL

# entry[].resource.text.div
HL7 Diagnostic Report

Status | UNKNOWN

# entry[].resource.text.div
HL7 Diagnostic Report

Status | UNKNOWN

# entry[].resource.text.div
3001130^Aminoglycoside

Status | FINAL

# entry[].resource.text.div
3001130^Aminoglycoside

Status | FINAL

# entry[].resource.text.div
HL7 Diagnostic Report

Status | UNKNOWN

# entry[].resource.text.div
3001130^Aminoglycoside

Status | FINAL

# entry[].resource.text.div
3001130^Aminoglycoside

Status | FINAL

# entry[].resource.text.div
3001130^Aminoglycoside

Status | FINAL

Name | Value | Interpretation | Reference Range | Status
3001130^Aminoglycoside | Not Tested | | | FINAL
3001131^AmpC 1 | Not Tested | | | FINAL
3001132^AmpC 2 | Not Tested | | | FINAL
3001133^Vancomycin | Not Tested | | | FINAL
3001134^Macrolide | Not Tested | | | FINAL
3001135^ESBL 1 | Not Tested | | | FINAL
3001137^ESBL 3 | Not Tested | | | FINAL
3001138^Carbapenemase 1 | Not Tested | | | FINAL
3001139^Carbapenemase 2 | Not Tested | | | FINAL
3001140^Metallo-BetaLactamase | Not Tested | | | FINAL
3001141^Methicillin | Not Tested | | | FINAL
3001142^Carbapenemase 3 | Not Tested | | | FINAL
3001143^Polymyxins | Not Tested | | | FINAL
3001144^Quinolone and fluoroquinolone 1 | Not Tested | | | FINAL
3001145^Quinolone and fluoroquinolone 2 | Not Tested | | | FINAL
3001146^Tetracycline | Not Tested | | | FINAL
3001147^Sulfonamide | Not Tested | | | FINAL
3001464^Metallo-BetaLactamase 2 | Not Tested | | | FINAL
300699^Providencia stuartii (UTI) | Not Detected | | | FINAL
300700^Staphylococcus saprophyticus (UTI) | Not Detected | | | FINAL
300701^Acinetobacter baumannii (UTI) | Not Detected | | | FINAL
300702^Citrobacter freundii (UTI) | Not Detected | | | FINAL
300703^Enterobacter cloacae (UTI) | Not Detected | | | FINAL
300704^Enterococcus faecium (UTI) | Not Detected | | | FINAL
300705^Klebsiella oxytoca (UTI) | Not Detected | | | FINAL
300706^Streptococcus agalactiae (UTI) | Not Detected | | | FINAL
300707^Morganella morganii (UTI) | Not Detected | | | FINAL
300708^Proteus vulgaris (UTI) | Not Detected | | | FINAL
300709^Pseudomonas aeruginosa (UTI) | Not Detected | | | FINAL
300710^Candida albicans (UTI) | Not Detected | | | FINAL
300711^Enterobacter aerogenes (UTI) | Not Detected | | | FINAL
300712^Enterococcus faecalis (UTI) | Not Detected | | | FINAL
300713^Escherichia coli (UTI) | Not Detected | | | FINAL
300714^Klebsiella pneumoniae (UTI) | Not Detected | | | UNKNOWN

# entry[].resource.text.div
Pathology report - Lung biopsy

Status | FINAL
Conclusion | DIAGNOSIS: Adenocarcinoma of lung, moderately differentiated. PD-L1 TPS: 80%. EGFR: Wild-type. ALK: Negative. ROS1: Negative.

# entry[].resource.conclusion
DIAGNOSIS: Adenocarcinoma of lung, moderately differentiated. PD-L1 TPS: 80%. EGFR: Wild-type. ALK: Negative. ROS1: Negative.

# entry[].resource.text.div
Pathology - Carotid endarterectomy specimen

Status | FINAL
Conclusion | SPECIMEN: Right carotid endarterectomyGROSS: 3.2cm atherosclerotic plaque with 80% luminal narrowing.MICRO: Fibrous cap with lipid-rich necrotic core. Intraplaque hemorrhage present. Moderate inflammatory infiltrate. No evidence of malignancy.DIAGNOSIS: Atherosclerotic plaque with features of instability (intraplaque hemorrhage, thin fibrous cap).

# entry[].resource.code.coding[].display
Pathology - Carotid endarterectomy specimen

# entry[].resource.conclusion
SPECIMEN: Right carotid endarterectomy

GROSS: 3.2cm atherosclerotic plaque with 80% luminal narrowing.

MICRO: Fibrous cap with lipid-rich necrotic core. Intraplaque hemorrhage present. Moderate inflammatory infiltrate. No evidence of malignancy.

DIAGNOSIS: Atherosclerotic plaque with features of instability (intraplaque hemorrhage, thin fibrous cap).

# entry[].resource.text.div
Pathology - Colonic biopsies

Status | FINAL
Conclusion | SPECIMEN: Terminal ileum and ascending colon biopsiesMICROSCOPIC:- Terminal ileum: Active chronic ileitis with granulomas, crypt distortion, and transmural inflammation consistent with Crohn disease- Ascending colon: Moderate active colitis with focal granulomas. No dysplasia.DIAGNOSIS: Active Crohn disease, ileocolonic involvement. No evidence of dysplasia.

# entry[].resource.conclusion
SPECIMEN: Terminal ileum and ascending colon biopsies

MICROSCOPIC:
- Terminal ileum: Active chronic ileitis with granulomas, crypt distortion, and transmural inflammation consistent with Crohn disease
- Ascending colon: Moderate active colitis with focal granulomas. No dysplasia.

DIAGNOSIS: Active Crohn disease, ileocolonic involvement. No evidence of dysplasia.

# entry[].resource.text.div
Pathology - Liver core biopsy

Status | FINAL
Conclusion | SPECIMEN: Liver, segment 6, core biopsyMICROSCOPIC: Benign cavernous hemangioma. Large vascular channels lined by flat endothelium without atypia. Adjacent liver parenchyma shows no significant pathology.DIAGNOSIS: Cavernous hemangioma of liver. Benign.

# entry[].resource.conclusion
SPECIMEN: Liver, segment 6, core biopsy

MICROSCOPIC: Benign cavernous hemangioma. Large vascular channels lined by flat endothelium without atypia. Adjacent liver parenchyma shows no significant pathology.

DIAGNOSIS: Cavernous hemangioma of liver. Benign.

# entry[].resource.text.div
Pathology — Colonic Biopsies, Detailed with IHC

Status | FINAL
Conclusion | GASTROINTESTINAL PATHOLOGY REPORTSPECIMEN A: Terminal ileum biopsies x4 (S25-2104A)SPECIMEN B: Ascending colon biopsies x3 (S25-2104B)SPECIMEN C: Transverse colon biopsies x2 (S25-2104C)SPECIMEN D: Duodenal biopsies x2 (S25-2104D)MICROSCOPIC:SPECIMEN A — Terminal Ileum:- Active chronic ileitis with marked architectural distortion- Non-caseating GRANULOMAS identified (3 granulomas across 4 fragments)- Transmural inflammation extending to muscularis mucosae- Crypt abscesses and cryptitis (neutrophilic infiltration)- Pyloric metaplasia (Paneth cell metaplasia in ileum — chronic injury marker)- Villous blunting and surface epithelial damage- Lamina propria expanded by lymphoplasmacytic infiltrate with eosinophils- No dysplasia identified- No viral cytopathic changesSPECIMEN B — Ascending Colon:- Moderate active colitis with focal granuloma formation (1 granuloma)- Patchy crypt architectural distortion (skip pattern)- Moderate cryptitis with occasional crypt abscesses- Basal lymphoid aggregates- No dysplasiaSPECIMEN C — Transverse Colon:- Essentially normal colonic mucosa- No inflammation, no granulomas- Confirms SKIP PATTERN of diseaseSPECIMEN D — Duodenum:- Mild duodenitis with increased intraepithelial lymphocytes (15/100 enterocytes)- No villous atrophy (excludes celiac disease)- Focally enhanced gastritis pattern- No granulomas- H. pylori: NEGATIVE (immunostain)SPECIAL STAINS / IHC: AFB (Ziehl-Neelsen): NEGATIVE (excludes tuberculosis) GMS: NEGATIVE (excludes fungal) CMV immunostain: NEGATIVE HSV immunostain: NEGATIVE CD3/CD20: Mixed T and B cell inflammatory pattern Ki-67: Increased proliferative activity in inflamed areasDIAGNOSIS:1. Terminal ileum: ACTIVE CHRONIC GRANULOMATOUS ILEITIS consistent with CROHN'S DISEASE2. Ascending colon: MODERATE ACTIVE COLITIS with granuloma, consistent with Crohn's involvement3. Transverse colon: NORMAL — skip lesion pattern supports Crohn's disease4. Duodenum: MILD DUODENITIS — may represent upper GI Crohn's involvement (focally enhanced gastritis pattern)5. No dysplasia in any specimen6. Negative for infection (TB, CMV, HSV, fungal)COMMENT: Histologic findings show active granulomatous inflammation in a skip pattern (ileum + ascending colon with normal transverse colon) classic for Crohn's disease. The presence of granulomas, transmural inflammation, and pyloric metaplasia support the diagnosis. Upper GI involvement is suggested by focally enhanced duodenitis. No dysplasia — surveillance colonoscopy in 1-2 years per guidelines.Reported by: Dr. L. Chandra, MD | GI PathologyReviewed by: Dr. A. Goldman, MD | Director of Surgical Pathology

# entry[].resource.code.coding[].display
Pathology — Colonic Biopsies, Detailed with IHC

# entry[].resource.code.text
Pathology — Colonic Biopsies, Detailed with IHC

# entry[].resource.conclusion
GASTROINTESTINAL PATHOLOGY REPORT

SPECIMEN A: Terminal ileum biopsies x4 (S25-2104A)
SPECIMEN B: Ascending colon biopsies x3 (S25-2104B)
SPECIMEN C: Transverse colon biopsies x2 (S25-2104C)
SPECIMEN D: Duodenal biopsies x2 (S25-2104D)

MICROSCOPIC:

SPECIMEN A — Terminal Ileum:
- Active chronic ileitis with marked architectural distortion
- Non-caseating GRANULOMAS identified (3 granulomas across 4 fragments)
- Transmural inflammation extending to muscularis mucosae
- Crypt abscesses and cryptitis (neutrophilic infiltration)
- Pyloric metaplasia (Paneth cell metaplasia in ileum — chronic injury marker)
- Villous blunting and surface epithelial damage
- Lamina propria expanded by lymphoplasmacytic infiltrate with eosinophils
- No dysplasia identified
- No viral cytopathic changes

SPECIMEN B — Ascending Colon:
- Moderate active colitis with focal granuloma formation (1 granuloma)
- Patchy crypt architectural distortion (skip pattern)
- Moderate cryptitis with occasional crypt abscesses
- Basal lymphoid aggregates
- No dysplasia

SPECIMEN C — Transverse Colon:
- Essentially normal colonic mucosa
- No inflammation, no granulomas
- Confirms SKIP PATTERN of disease

SPECIMEN D — Duodenum:
- Mild duodenitis with increased intraepithelial lymphocytes (15/100 enterocytes)
- No villous atrophy (excludes celiac disease)
- Focally enhanced gastritis pattern
- No granulomas
- H. pylori: NEGATIVE (immunostain)

SPECIAL STAINS / IHC:
  AFB (Ziehl-Neelsen):  NEGATIVE (excludes tuberculosis)
  GMS:                   NEGATIVE (excludes fungal)
  CMV immunostain:       NEGATIVE
  HSV immunostain:       NEGATIVE
  CD3/CD20:             Mixed T and B cell inflammatory pattern
  Ki-67:                Increased proliferative activity in inflamed areas

DIAGNOSIS:
1. Terminal ileum: ACTIVE CHRONIC GRANULOMATOUS ILEITIS consistent with CROHN'S DISEASE
2. Ascending colon: MODERATE ACTIVE COLITIS with granuloma, consistent with Crohn's involvement
3. Transverse colon: NORMAL — skip lesion pattern supports Crohn's disease
4. Duodenum: MILD DUODENITIS — may represent upper GI Crohn's involvement (focally enhanced gastritis pattern)
5. No dysplasia in any specimen
6. Negative for infection (TB, CMV, HSV, fungal)

COMMENT: Histologic findings show active granulomatous inflammation in a skip pattern (ileum + ascending colon with normal transverse colon) classic for Crohn's disease. The presence of granulomas, transmural inflammation, and pyloric metaplasia support the diagnosis. Upper GI involvement is suggested by focally enhanced duodenitis. No dysplasia — surveillance colonoscopy in 1-2 years per guidelines.

Reported by: Dr. L. Chandra, MD | GI Pathology
Reviewed by: Dr. A. Goldman, MD | Director of Surgical Pathology