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2.14 Integrated Examples

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 Patient case 1

The 69 year old Pieter van den Heuvel is charged with some 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 Patient contact information

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

2.14.1.2 Patient contact information

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

2.14.1.3 Anamnese

2.14.1.4 Physical investigation

2.14.1.5 Additional research

2.14.1.6 Policy

2.14.1.7 Conclusion

2.14.2 Patient case 2

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

2.14.2.1 Patient contact information

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