3-Dongyeong Seong结构性内镜检查报告

StructuredEndoscopyReporting2017.8.192Source:NationalCancerCenter,http://www.ncc.re.krNationalcancerscreeninginKorea•CanceristheleadingcauseofdeathinKoreagramNCSPhasbeenimplementedandexpandedsince9•Thetargetsaretop5cancersCancerTargetpopulationAged≥40arsUpperendoscopyorUGILiverHigh-riskgroupaged≥40years0.5UltrasonographyandAFPlAged≥50arsFOBT,orcolonoscopyBreastWomenaged≥40years2MammographyCervixuteriWomenaged≥40years2PapsmearUGIuppergastrointestinalseries,AFP:alpha-fetoprotein,FOBT:fecaloccultbloodtestInthecaseofanabnormalityonFOBTcolonoscopyoradoublecontrastbariumenemaisrecommendedTrendsofgastriccancerscreening(from2002to2011)•Overall,gastriccancerscreeningratescontinuouslyincreased•TheendoscopyexaminationisrapidlyincreasingingisnotavailableyetinKorea◦PercentageofparticipantswhounderwentendoscopyviatheNCSP02002200320042005200620072008200920102011erscreeningNoofupperendoscopySource:GastricCancerScreeningUptakeTrendsinKorea:ResultsfortheNationalCancerScreeningProgramFrom2002to2011,3Medicine(Baltimore),2015Feb;94(8):e533.4ProcedureerelatedinformationClinicalinformationProcedureerelatedinformationClinicalinformationfdiseasesmedicationsproceduresetcEndoscopicfindingandtheirattributesizenumberetcConclusionationsconclusionsandrecommendationsofdiagnosesandproceduresnYesmidazolammgpethidinemgevelofsedationmoderateparadoxicalresponsenoAntispasmodicscimetropiummgYeslinformationFDthromboticsNocalfindingsSFreeverallinearhyperemicstreakswerenotedideofprepyloricantrumaboutmicelevatedlesionwithcentralirregularonwithhematinwasseenBxxreeclusionsuperficialgastritisColonoscopyreportofSMConoscopylinformationdicalHxFDthromboticsNoFHxofcoloncancer:Lastcolonoscopy:YesmidazolammgpethidinemgateparadoxicalresponsenoispasmodicscimetropiummgYesalrectalexaminationwasnormalowelpreparationwasfairlintubationtimewasaboutdrawaltimewasaboutFAIwasinserteduptotheterminalileumlonoscopicfindingshvenousdilatationsandhypertrophiedanalpapillajustabovedentatelinewerenoticed.aboutcmsizedIspolypwasseenandwasremovedbycoldbiopsy#1x2)aboutcmsizedIspolypwasseenandwasremovedbycoldbiopsy#2x2)ovedbybiopsyforcephemorrhoidentnClinicalinformation-Historyofdiseases,medications,procedures,etc.Procedureerelatedinformationsedation,bowelpreparation,etc.ColonoscopicfindingandtheirattributesizenumberetcImpressionationsconclusionsandrecommendationsofdiagnosesandproceduresComment5tionalcomments5FUplanBenefitsofstandardizedstructuredreportingleadingtobettercommunicationrpatientcare•OffermachineprocessableinicaldecisionCDS•SupportsecondaryusescalresearchSource:Structuredandtemplatedreporting:Anoverview,http:///articles/structured-and-templated-reporting-an-overview6BenefitsoftheDICOMStructuredReport,JDigitImaging.2006Dec;19(4):295–306.EffortsforstandardizedstructuredreportingRadiologicalSocietyofNorthAmerica(RSNA)ReportingInitiative-Target:Radiology(X-ray,MRI,Mammography,sonography,etc.)StructuredReporting-Target:Radiology,CardiologyInternationalcollaborationoncancerreportingICCR)-Target:PathologyMinimalStandardTerminologyofgastrointestinalendoscopy(MST)byWEO-Target:EndoscopySource:http://,http:///pixelmed/DICOMSR.book.pdf,http://www.iccr-,7/resources/minimal-standard-terminology-mstintestinalendoscopyMSTdoscopicfindingscopyOrganizationWEOsforindicationsproceduresextentofexaminations,etc.findingsentssarudinglesionstlesionsatedlesions8Source:Organization,W.E.MINIMALSTANDARDTERMINOLOGYFORGASTROINTESTINALENDOSCOPY-MST3.0,WorldEndoscopyOrganization9Source:LarsAabakken.Endoscopyreporting.ESGEEndorsedEvents2012MSTstructureSource:Aabakken,L.,etal.(2014)."Standardizedendoscopicreporting."JGastroenterolHepatol29(2):234-240.DefineitemsforendoscopyreportnPasthistorydiseaseprocedure,family,etc.)ionreasonforendoscopynanddrugsdoscopeusedQualityofcleansing/visualizationceduretimetotaltimetimetocecumwithdrawaltimeLesionsandtheirattributeslocationsize,number,etc.)lingtypeofsampleraproceduraleventsAssessmentionsconclusionsandrecommendationsfdiagnosesandproceduresItemsandtheirvaluesValuesistoryofdiseasesistoryofprocedurestoryofdrugstoryoffamilyrdiseasesproceduresanddrugsopyulcerCrohnsdiseasespectomyspERCPromboticesetsforsymptomsanddiseasessiaweightlossdiverticulaionispasmodicofsedationooorsedationdrugderateminimalesetforendoscopicdevicesleansingntgoodfairpoortocecumwaltimexxminxxsecEndoscopicfindings(fromMST)UpperendoscopyonlyColonoscopyonlyEndoscopicfindings–attributes&values(fromMST)ttinepartustructurettinepartustructuregustructurenaturestrthagusthpartsAfferentAfferentloopofjejunumejunumeriorwallTopographicalmodifierproximalmiddistalcenterbelowetc14Topographicalmodifierproximalmiddistalcenterbelowetc15nepartalstructureealstructureAppendixnalileumuspartalnepartalstructureealstructureAppendixnalileumuspartalcanalstructureeofcolicflexureructuresecolonstructureureofcolonngcolonstructurenorectaljunctioncolonoscopynBindingstandardterminologyionnceptsrmsinUMLSnC0038351|ENG|P|L