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2.14 2.11 Integrated Examples

FHIR Infrastructure Work Group

Maturity Level : N/A

Ballot Status : DSTU 2

These integrated examples are the result of choosing several real world healthcare records from a Dutch healthcare institution and representing them using FHIR resources. They are made published here for several reasons:

• To test that the resources are fit for purpose using real cases
• So that the available resource examples include real cases
• So that applications have real world clinical cases to use in development and prototyping

2.14.1 2.11.1 Patient case 1

The 69 year old Pieter van den Heuvel is charged diagnosed with some several serious diseases over the last few years. In the spring and summer of 2011, Pieter had complains of fatigue, dyspnea and even fainting. After visiting his physician, Pieter was referred to the cardiologist for further examination. At the hospital a malfunction of the heart valve was diagnosed and eventually replaced. Pieter recovered well in the next 2 months, but probably needs a life time prescription on blood pressure reducing medication. In the summer of 2012, Pieter again visited his physician for a chest injury after he fell from the stairs. By coincidence, the doctor noticed a suspicious stain on the X-thorax and performed some additional tests on Pieter. After the results, Pieter was diagnosed with early stage non-small cell lung cancer. Fortunately, the tumor didn't spread to other parts of the body. Tumor type and location made it possible to perform a partial lobectomy in the right lung. After his recovery, Pieter was submitted to a high risk control group for yearly screening.

In 2013, Pieter was charged with an increasing neck swelling, a stiff neck and difficulty swallowing. Because of breathing problems, Pieter was urgently admitted to the hospital. An upper respiratory infection caused a retropharyngeal abscess in the back of the throat. Surgery was needed to remove the abscess. The surgeons recommended a tracheotomy during the surgery, so there was less change of complications during the abscess removal. A tracheotomy was intubated before the surgery. After the removal of the retropharyngeal abscess, the tracheotomy was extubated as the swelling was reduced and normal breathing became reinstated.

2.14.1.1 2.11.1.1 Patient contact demographic information

Patient name: 

Patient name: Pieter van den Heuvel

Patient number: 0108173
Date of birth: 17-11-1944
Gender: Male

2.14.1.2 2.11.1.2 Patient contact information

Address: van Egmondkade 23
Zip code: 1024 RJ
City: Amsterdam
Phone: +31648352638
email: p.heuvel@gmail.com

Intakes

intake date	surgery date	practitioner	specialism	diagnose	procedure	care plan	surgery code	SNOMED CT code	related encounter
26-6-2011	27-6-2011	P. Voigt	CTC (Cardio-thoracale Chirurgie)	Heart valve disorder	Heart valve replacement	CP2903	1000263502	64915003	v1451
6-7-2012	7-7-2012	M.I.M. Versteegh	CTC (Cardio-thoracale Chirurgie)	NSCLC - Non-small cell lung cancer	partial lobectomy	CP2934	1000263813	173171007	v3251
22-3-2013	22-3-2013	A.P.M. Langeveld	ENT	Retropharyngeal abscess	Trachea-tracheotomy	CP2938	1000050465	48387007	v6751
24-3-2013	24-3-2013	E.M.J.M. van den broek	ENT	Retropharyngeal abscess	retropharyngeal abscess	CP3953	1000049161	172960003	v6751
27-3-2013	27-3-2013	R.J.P. Briet	ENT	Retropharyngeal abscess	Trachea-extubatie	CP1283	1000050159	309812005	v6751

Active medication

medication	hopital/home	dose	admission route	start date	presciber	SNOMED CT code	prescription nu
Salbutamol+ipratropium bromide	hopital	3/4 times daily 1 flacon	inhaler	8-4-2013	R.A. van den Berk	320442002	2983
rosuvastatine	hopital	1 time daily 10 mg	oral	7-7-2011	R.A. van den Berk	408036003	1029
Tolbutamide	home	3 times daily 500 mg	oral	7-7-2011	S.M. Heps	325267004	8473
metoprolol	home	1 time daily 50 mg	oral	1-5-2011	S.M. Heps	318475005	9517
enalapril	home	1 time daily 5 mg	oral	1-5-2011	S.M. Heps	318851002	7119

Device

device	hopital/home	dose	admission route	start date	presciber	SNOMED CT code
Feeding tube	hopital	N.A.	tube	10-4-2013	R.A. van den Berk	61420007

Lab results

diagnostic blood report
date	substance	value	status
2013-04-02	glucose	6,3 mmol/l	abnormal
2013-04-02	base excess	12,6 mmol/l	abnormal
2013-04-02	carbon dioxide	6,2 mm[Hg]	abnormal
2013-04-02	erytrocyten	18,7 g/dl	abnormal
2013-04-02	Hemoglobin	7,5 g/dl	abnormal

2.14.1.3 2.11.1.3 Anamnese

date: 8-6-2012 Bronchoscopy; several biopsy specimen were taken from pathological mucosa, right main bronchus specimen send for pathologic analysis. Bronchoscopy because of atelectasis right. X-thorax; increase in atelectasis and pleural liquid. Bronchoscopy;
-fluids drained from right main bronchus
-pathalogic mucous membrane right bronchus, easily bleeding
-left bronchial system open date: 18-3-2013 Antiobiotic policy with retropharyngeal abscess with prolapse to the mediatinum. No surgical possibility to fully drain the mediatinum.

2.14.1.4 2.11.1.4 Physical investigation

date: 18-3-2013 Neck; swelling and redness pretracheal extending to chest. No fluctation, however induration is present. Swelling back pharynx, also present in postcricoid area. Light stridor sound when breathing. Overall condition is good. Scoop; little supraglottic swelling, vocal chords not judgable.

2.14.1.5 2.11.1.5 Additional research

CT thorax: no mediastinal/retropharyngal collering of the fluid collections. Diffuse edema retro/parapharyngeal and mediastinitis. Preoperative culture shows; S pyogenes, sensitivity for peneciline and E. cloacae, sensitivity for Salbutamol.

2.14.1.6 2.11.1.6 Policy

Stop Salbutamol prescription. Continue penicilin and start salbutamol supplementation. Total treatment time is approximatly 6 weeks. In consultation with the IC/anesthesia; intubation. Analyse lower respiratory tract.

2.14.1.7 2.11.1.7 Conclusion

Extubation on OR. Normal voice, no stridor. However, hypoxic at low respiratory tract obstruction with 84% O2 and rapid breathing.

2.14.2 2.11.2 Patient case 2

Patient name: 

Patient name: Roel Bor

Patient number: 123456789
Date of birth: 1960-03-13
Gender: Male

2.14.2.1 2.11.2.1 Patient contact information

Address: Bos en Lommerplein 280
Zip code: 1055 RW
City: Amsterdam
Phone: +31612345678

Roel Bor is in his mid-fifties, works for an IT-company and has two healthy children and a wife. His uncle unfortunately was less healthy and died of cancer. At the end of 2012, Roel was also diagnosed with a tumor in the Erasmus Medical Center. His tumor is located in the head-neck area. The standard treatment for that is TPF-chemotherapy. The tumor is not fully curable due to its position, but it was optimally minimized with the therapy in the AUMC. Two severe complications followed the treatment, namely bacterial sepsis (streptococcus aureus) and renal failure. Both were stabilized within a short period through medication (see care plan). Roel thereafter had his ups and downs with the last known condition of a severe fever, for which he received among other treatment (paracetamol). On a side-note and as a final statement: the patient suffers from house dust allergy.

Intakes

practitioner	organization	careplan	start date	substance	condition	other participant	procedure	encounter ID	surgery code	SNOMED CT code
A. Bronsig	Artis University Medical Center	CP3928	2013-03-11	potassium	fever	Carla Espinosa		20130404	100028475	64915003
A. Bronsig	Artis University Medical Center	CP7364			malignant tumor		chemotherapy	20130128	100028475	363346000
A. Bronsig	Artis University Medical Center	CP8766	2013-03-11		Bacterial sepsis	Luigi Maas	observation	20130311	100028475	363346000

Diagnoses

practitioner	date	encounter	reason	condition	medication	medication prescription	procedure	diagnostic report	issued by
A. Bronsig	28-1-2013	20130128	chemotherapy	malignant tumor			chemotherapy	CT scan	BUMC
A. Bronsig	4-3-2013	20130404	fever	fever	paracetamol	Paracetamol 500mg tablet
A. Bronsig	11-3-2013	20130311	sepsis	Bacterial sepsis	Flutacisone + Salmeterol	Salmeterol+fluticasone inhaler		blood culture	AUMC
A. Bronsig	11-3-2013	20130311	renal	Renal insufficiency	Flucloxacillin	Injected floxacillin		blood culture	AUMC

Observations

practitioner	date	observation	value	status	SNOMED CT code
Luigi Maas	11-3-2013	Blood culture for bacteria	Gram-positive bacteria	positive	8745002
A. Bronsig 4-4-2013 BMI 31.31 high 60621009 A. Bronsig	4-4-2013	temperature taken	39 degrees Celsius1	high	89003005
A. Bronsig	4-4-2013	Serum bicarbonate measurement	28mmol/L	normal	271239003
Luigi Maas	4-4-2013	Serum creatinine raised	122 umol/L	high	166717003
Luigi Maas	4-4-2013	Epidermal Growth Factor Receptor	Negative for EGF receptor expression (Non-small cell lung cancer)	negative	427038005