Case study 1 Suspicion of deep vein thrombosis A patient, Tobias Timmermann, presents to Dr. med. Marc Mustermann at the Olten group practice on 09.03.2016. He verbally identifies himself via his master data as Tobias Timmermann, 01.01.1984. He reports unclear leg pain in the left lower leg as well as simultaneously occurring respiratory pain and cough. The doctor carries out the anamnesis and physical examination and prescribes the following laboratory parameters: Blood cell count incl. differentiation CRP D-dimer The doctor carries out the Blood count and the CRP determination himself by means of point of care diagnostics, the D-dimer diagnostics is prescribed as quantitative diagnostics in an external sending laboratory. To obtain the sample, a Blood sample is taken lying down (1 EDTA tube, 2 citrate tubes of 5 ml). The order is transmitted to the external laboratory and the sample is sent to the external dispatch laboratory by courier ordered by telephone. The results of the internal point of care diagnostics (Blood count and CRP) are entered in the patient`s laboratory sheet in the doctor`s office software (manually or via locally installed electronic interfaces). A prescription is therefore issued by the doctor to the patient for self-administration of an anti-thrombotic agent. The results of the sending-in laboratory arrive electronically at the GP`s on the same evening and are also entered in the patient`s laboratory sheet. By using the present exchange format, this process can be fully automated. After a telephone enquiry by the doctor at the sending laboratory due to a borderline D-dimer result, the information is given that a deep vein thrombosis cannot be ruled out in this situation by means of D-dimer and the patient is therefore called back the next day for a sonography of the legs. As it is probably a primary leg vein thrombosis, Dr Eva Erlenmeier from the Pipette laboratory sends feedback to Dr Mustermann with the recommendation to carry out a thrombophilia screening, which includes the following analyses: Quick, aPTT, fibrinogen, antithrombin (funct.), thrombin time I 2.5 NIH/ml, APC resistance, D-dimers, protein C, (aPTT method), protein S antigen. The analyses can be carried out directly from the samples of the citrate tubes sent along.
Laboratory Order with Service Request 1-tvt
id: TobiasTimmermann meta: identifier: 80756011110123400003 name: Tobias Timmermann gender: MALE birthDate: Jan 01, 1981 maritalStatus: unverheiratet (Details : {$ech-11-maritalstatus code '5' = '5', given as 'unverheiratet'}) Communications - Language Preferred * Deutsch (Schweiz) (Details : {urn:ietf:bcp:47 code 'de-CH' = 'German (Region=Schweiz)) true
Generated Narrative: Practitioner MarcMustermann Profile: CH Core Practitioner identifier: GLN/7601000050700, urn:oid:2.16.756.5.30.1.123.100.2.1.1/L248519 name: Marc Mustermann (Official) telecom: ph: 033 444 22 11(Work), marc.mustermann@gruppenpraxis.ch
Generated Narrative: PractitionerRole MarcMustermannGruppenpraxis Profile: CH Core PractitionerRole practitioner: Practitioner Marc Mustermann (official) organization: Organization Gruppenpraxis Olten
Generated Narrative: Organization Gruppenpraxis Profile: CH Core Organization EPR identifier: GLN/7601000241115 name: Gruppenpraxis Olten telecom: +41555556677, info@gruppenpraxis.ch, http://www.gruppenpraxis.ch address: Gerbergasse 12 Olten 4600 CH
Generated Narrative: Practitioner EvaErlenmeyer Profile: CH Core Practitioner identifier: GLN/7601000050717, urn:oid:2.16.756.5.30.1.123.100.2.1.1/Y274589 name: Eva Erlenmeyer (Official) telecom: ph: 033 444 55 66(Work), eva.erlenmeyer@labor-pipette.ch
Generated Narrative: Organization LaborPipette Profile: CH Core Organization identifier: GLN/7601000234407 name: Labor Pipette telecom: +41223345566, info@labor-pipette.ch, http://www.labor-pipette.ch address: Laborstrasse 23 Olten 4600 CH
Generated Narrative: PractitionerRole EvaErlenmeyerLaborPipette Profile: CH Core PractitionerRole identifier: urn:oid:2.16.756.5.30.1.123.100.2.1.1/K333333 practitioner: Practitioner Eva Erlenmeyer (official) organization: Organization Labor Pipette
Generated Narrative: Coverage HealthInsuranceCardTobiasTimmermann Profile: CH Core Coverage identifier: Insurance Card Number/80756011110123400003 status: Active type: Krankenversicherung (obligat.) subscriber: Tobias Timmermann Male, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400003) beneficiary: Tobias Timmermann Male, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400003) period: ?? --> 2024-12-31 payor: Krankenkasse AG (Identifier: http://example.org/insurer/123456789)
Generated Narrative: Condition ConditionRenalInsufficiency clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item severity: Mild (qualifier value) code: Chronic renal insufficiency (disorder) subject: Tobias Timmermann onset: 2023-08-05 recordedDate: 2023-10-05 asserter: Tobias Timmermann
Generated Narrative: Specimen Serum-1-tvt identifier: 48736-12345-75465 accessionIdentifier: 4e88a-12345-dd888 status: Available type: Serum specimen (specimen) subject: Tobias Timmermann Male, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400003) Collections - Collector Collected[x] BodySite FastingStatus[x] * Practitioner Marc Mustermann (official) 2015-08-16 06:40:17+0000 Structure of median cubital vein (body structure) Patient was fasting prior to the procedure. Containers - Type * General specimen container (physical object)
Structure of median cubital vein (body structure)
Patient was fasting prior to the procedure.
General specimen container (physical object)
Generated Narrative: Specimen Blood-coag-1-tvt identifier: 48736-55555-75465 accessionIdentifier: 4e88a-66666-dd888 status: Available type: Blood sample subject: Tobias Timmermann Male, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400003) receivedTime: 2023-12-01 16:40:17+0000 Collections - Collector Collected[x] * Practitioner Marc Mustermann (official) 2023-12-01 17:00:17+0000 Processings - Time[x] * 2023-12-01 17:00:17+0000 --> 2023-12-01 17:30:17+0000 Containers - Identifier Description Type Additive[x] * 4e88a-bc987-dd888-00001-bcoag S-Monovette grün Blood collection Luer adaptor 3.8% Citrate
Generated Narrative: Specimen Blood-1-tvt status: Available type: Blood sample subject: Tobias Timmermann Male, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400003) Collections - Collector Collected[x] BodySite * Practitioner Marc Mustermann (official) 2015-08-16 06:40:17+0000 Structure of superficial vein of left upper limb (body structure) Containers - Type * General specimen container (physical object) note: Specimen is grossly lipemic
Structure of superficial vein of left upper limb (body structure)
Generated Narrative: ServiceRequest 1-tvt-ServiceRequest-0 Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 status: Active intent: Original Order priority: Urgent subject: Tobias Timmermann Male, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400003) requester: PractitionerRole reasonCode: Deep venous thrombosis of lower extremity (disorder) insurance: Coverage: identifier = Insurance Card Number; status = active; type = Krankenversicherung (obligat.); period = (?) --> 2024-12-31
Deep venous thrombosis of lower extremity (disorder)
Generated Narrative: ServiceRequest 1-tvt-ServiceRequest-1 Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest: identifier = Placer Identifier: Y274589; status = active; intent = original-order; priority = urgent; reasonCode = Deep venous thrombosis of lower extremity (disorder) status: Active intent: Original Order priority: Urgent code: CBC panel - Blood by Automated count subject: Tobias Timmermann Male, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400003) requester: PractitionerRole reasonCode: Deep venous thrombosis of lower extremity (disorder) insurance: Coverage: identifier = Insurance Card Number; status = active; type = Krankenversicherung (obligat.); period = (?) --> 2024-12-31 specimen: Specimen: status = available; type = Blood sample; note = Specimen is grossly lipemic
Generated Narrative: ServiceRequest 1-tvt-ServiceRequest-2 Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest: identifier = Placer Identifier: Y274589; status = active; intent = original-order; priority = urgent; reasonCode = Deep venous thrombosis of lower extremity (disorder) status: Active intent: Original Order priority: Urgent code: CBC W Auto Differential panel - Blood subject: Tobias Timmermann Male, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400003) requester: PractitionerRole reasonCode: Deep venous thrombosis of lower extremity (disorder) insurance: Coverage: identifier = Insurance Card Number; status = active; type = Krankenversicherung (obligat.); period = (?) --> 2024-12-31 specimen: Specimen: status = available; type = Blood sample; note = Specimen is grossly lipemic
Generated Narrative: ServiceRequest 1-tvt-ServiceRequest-3 Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest: identifier = Placer Identifier: Y274589; status = active; intent = original-order; priority = urgent; reasonCode = Deep venous thrombosis of lower extremity (disorder) status: Active intent: Original Order priority: Urgent code: Short Fibrin D-dimer FEU and DDU panel - Platelet poor plasma subject: Tobias Timmermann Male, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400003) requester: PractitionerRole reasonCode: Deep venous thrombosis of lower extremity (disorder) insurance: Coverage: identifier = Insurance Card Number; status = active; type = Krankenversicherung (obligat.); period = (?) --> 2024-12-31 specimen: Specimen: identifier = 48736-55555-75465; accessionIdentifier = 4e88a-66666-dd888; status = available; type = Blood sample; receivedTime = 2023-12-01 16:40:17+0000
Short Fibrin D-dimer FEU and DDU panel - Platelet poor plasma
Generated Narrative: ServiceRequest 1-tvt-ServiceRequest-4 Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest: identifier = Placer Identifier: Y274589; status = active; intent = original-order; priority = urgent; reasonCode = Deep venous thrombosis of lower extremity (disorder) status: Active intent: Original Order priority: Urgent code: C reactive protein [Mass/Volume] in Serum or Plasma subject: Tobias Timmermann Male, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400003) requester: PractitionerRole reasonCode: Deep venous thrombosis of lower extremity (disorder) insurance: Coverage: identifier = Insurance Card Number; status = active; type = Krankenversicherung (obligat.); period = (?) --> 2024-12-31 specimen: Serum specimen
C reactive protein [Mass/Volume] in Serum or Plasma
Generated Narrative: ServiceRequest 1-tvt-ServiceRequest-5 Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest: identifier = Placer Identifier: Y274589; status = active; intent = original-order; priority = urgent; reasonCode = Deep venous thrombosis of lower extremity (disorder) status: Active intent: Original Order priority: Urgent code: 25-Hydroxyvitamin D3+25-Hydroxyvitamin D2 [Mass/volume] in Serum or Plasma subject: Tobias Timmermann Male, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400003) requester: PractitionerRole reasonCode: Limitation of Vit. D Lab Analyse reasonReference: Condition Chronic renal insufficiency (disorder) insurance: Coverage: identifier = Insurance Card Number; status = active; type = Krankenversicherung (obligat.); period = (?) --> 2024-12-31 supportingInfo: Condition Chronic renal insufficiency (disorder) specimen: Serum specimen
25-Hydroxyvitamin D3+25-Hydroxyvitamin D2 [Mass/volume] in Serum or Plasma