臺灣核心實作指引(TW Core IG)
0.2.2 - Trial Use

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: 堅果過敏或不耐症 - JSON Representation

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{
  "resourceType" : "AllergyIntolerance",
  "id" : "all-nut-example",
  "meta" : {
    "profile" : [
      🔗 "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/AllergyIntolerance-twcore"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>堅果過敏</b></h3><p><b>臨床狀態</b>:Active <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical\">AllergyIntoleranceClinicalStatusCodes</a>#active)</span></p><p><b>驗證狀態</b>:Confirmed <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://terminology.hl7.org/CodeSystem/allergyintolerance-verification\">AllergyIntoleranceVerificationStatusCodes</a>#confirmed)</span></p><p><b>根本原因或運作機制</b>:Allergy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/allergy-intolerance-type\">AllergyIntoleranceType</a>#allergy)</span></p><p><b>確定的物質的類別</b>:Food <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/allergy-intolerance-category\">AllergyIntoleranceCategory</a>#food)</span></p><p><b>嚴重程度</b>:High Risk <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/allergy-intolerance-criticality\">AllergyIntoleranceCriticality</a>#high)</span></p><p><b>過敏或不耐症的識別</b>:堅果過敏(Nut allergy) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://snomed.info/sct\">SNOMED CT</a>#91934008)</span></p><p><b>過敏或不耐症被識別的時間</b>:2023-09-03T10:15:00</p><p><b>病人</b>:<a href=\"Patient-pat-example.html\">Patient/pat-example</a> \"陳加玲\"</p><p><b>紀錄者</b>:<a href=\"Practitioner-pra-dr-example.html\">Practitioner/pra-dr-example</a> \"王依昇\"</p><p><b>被記錄的日期</b>:2023-09-03T14:30:00</p><p><b>關於過敏的資訊來源</b>:<a href=\"Practitioner-pra-nurse-example.html\">Practitioner/pra-nurse-example</a> \"陳莉\"</p><p><b>最後一次已知反應發生的日期與時間</b>:2023-09-03T14:30:00</p><p><b>暴露於此過敏或不耐症物質的不良反應</b>:</p><blockquote><p><b>過敏產生的特定物質或醫藥產品</b>:alpha-1,4-Glucan-protein synthase (uridine diphosphate-forming)(Medicinal product containing penicillin and acting as antibacterial agent (product)) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://snomed.info/sct\">SNOMED CT</a>#3193000)</span></p><p><b>與此事件相關的臨床症狀/體徵</b>:Anaphylaxis (disorder))<span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ( <a href=\"http://snomed.info/sct\">SNOMED CT</a>#39579001)</span></p><p><b>對整個過敏事件的描述</b>:皮膚發癢、紅腫</p><p><b>嚴重程度</b>:Severe <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/reaction-event-severity\">AllergyIntoleranceSeverity</a>#severe)</span></p><p><b>如何接觸到該物質</b>:口服(Oral use) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://snomed.info/sct\">SNOMED CT</a>#26643006)</span></p><p><b>備註</b>:患者在食用堅果後出現皮膚發癢和紅腫,症狀於2023年9月3日下午2:30發作</p></blockquote></div>"
  },
  "clinicalStatus" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical",
        "code" : "active",
        "display" : "Active"
      }
    ],
    "text" : "Active"
  },
  "verificationStatus" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification",
        "code" : "confirmed",
        "display" : "Confirmed"
      }
    ],
    "text" : "Confirmed"
  },
  "type" : "allergy",
  "category" : [
    "food"
  ],
  "criticality" : "high",
  "code" : {
    "coding" : [
      {
        "system" : "http://snomed.info/sct",
        "code" : "91934008",
        "display" : "Nut allergy"
      }
    ],
    "text" : "堅果過敏"
  },
  "patient" : {
    🔗 "reference" : "Patient/pat-example",
    "display" : "陳加玲"
  },
  "onsetDateTime" : "2023-09-03T10:15:00Z",
  "recordedDate" : "2023-09-03T14:30:00Z",
  "recorder" : {
    🔗 "reference" : "Practitioner/pra-dr-example",
    "display" : "王依昇"
  },
  "asserter" : {
    🔗 "reference" : "Practitioner/pra-nurse-example",
    "display" : "陳莉"
  },
  "lastOccurrence" : "2023-09-03T14:30:00Z",
  "note" : [
    {
      "text" : "患者對堅果與添加堅果的食品過敏,可能導致皮膚發癢、紅腫"
    }
  ],
  "reaction" : [
    {
      "substance" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "3193000",
            "display" : "alpha-1,4-Glucan-protein synthase (uridine diphosphate-forming)"
          }
        ],
        "text" : "alpha-1,4-Glucan-protein synthase (uridine diphosphate-forming)"
      },
      "manifestation" : [
        {
          "coding" : [
            {
              "system" : "http://snomed.info/sct",
              "code" : "39579001",
              "display" : "Anaphylaxis (disorder)"
            }
          ]
        }
      ],
      "description" : "皮膚發癢、紅腫",
      "severity" : "severe",
      "exposureRoute" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "26643006",
            "display" : "Oral use"
          }
        ],
        "text" : "口服"
      },
      "note" : [
        {
          "text" : "患者在食用堅果後出現皮膚發癢和紅腫,症狀於2023年9月3日下午2:30發作"
        }
      ]
    }
  ]
}