R4 Ballot #2 (Mixed Normative/Trial use)

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7.16 Integrated Examples

FHIR Infrastructure Work GroupMaturity Level: N/ABallot Status: Informative

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 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

7.16.1 Patient case 1

The 69 year old Pieter van den Heuvel is diagnosed with several serious diseases over the last few years. In the spring and summer of 2011, Pieter had complaints 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.

7.16.1.1 Patient demographic information 

Patient name: Pieter van den Heuvel
Patient number: 0108173
Date of birth: 17-11-1944
Gender: Male

7.16.1.2 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 specializm 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

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

7.16.1.3 Anamnese

date: 8-6-2012 Bronchoscopy; several biopsy specimens were taken from pathological mucosa, right main bronchus specimen sent for pathologic analysis. Bronchoscopy because of atelectasis right. X-thorax; increase in atelectasis and pleural liquid. Bronchoscopy;
-fluids drained from right main bronchus
-pathologic 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.

7.16.1.4 Physical investigation

date: 18-3-2013 Neck; swelling and redness pretracheal extending to chest. No fluctuation, 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.

7.16.1.5 Additional research

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

7.16.1.6 Policy

Stop vancomycin prescription. Continue penicillin and start vancomycin supplementation. Total treatment time is approximately 6 weeks. In consultation with the IC/anesthesia; intubation. Analyze lower respiratory tract.

7.16.1.7 Conclusion

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

7.16.2 Patient case 2 

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

7.16.2.1 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 BUMC
A. Bronsig 4-3-2013 20130404 fever fever
A. Bronsig 11-3-2013 20130311 sepsis Bacterial sepsis AUMC
A. Bronsig 11-3-2013 20130311 renal Renal insufficiency 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 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