Case study 2 Suspicion of whooping cough A mother visits the family doctor Peter Presto of the Olten group practice with her 6-year-old son Emil Kummer, born 5 May 2014, because the child has been coughing increasingly for a fortnight, with cramping cough attacks, and has a fever. The doctor`s receptionist measures the fever, takes a fingertip Blood sample from the son, determines the CRP and prepares a Blood smear. The doctor suspects a viral infection, but wants to rule out whooping cough, although the child has been vaccinated against it. As he is under time pressure due to an emergency, he does not want to do the necessary throat swab himself, but asks the mother to accompany the child to the nearby laboratory to have the swab done in peace. He prepares a laboratory order to carry out a pertussis PCR on the child`s throat swab and gives the order to the mother. The mother herself is not sure whether she herself has been vaccinated against pertussis. Consequently, the family doctor Peter Presto gives her the pertussis vaccination right away and recommends that the same be done for the child`s father and grandparents. In the meantime, the MPA has looked at the son`s Blood smear under the microscope and finds a lot of reactive lymphocytes, which seem suspicious to her. She is unsure and asks the doctor, who gives the order to give the child`s Blood smears to the mother and also to have them examined more closely in the laboratory. The mother arrives at the laboratory with her son, where the doctor`s order is first to establish the son`s identity. Then a pharyngeal swab and a right cubital venepuncture are taken from the child in the laboratory`s Blood collection room and passed on to the laboratory together with the Blood smears and the doctor`s examination order.
Laboratory Order 2-pertussis with Service Request
Laboratory Order with Service Request 2-pertussis
id: EmilKummer meta: identifier: 80756011110123400004 name: Emil Kummer gender: MALE birthDate: May 05, 2014 maritalStatus: ledig (Details : {$ech-11-maritalstatus code '1' = '1', given as 'ledig'}) Communications - Language Preferred * Deutsch (Schweiz) (Details : {urn:ietf:bcp:47 code 'de-CH' = 'German (Region=Schweiz)) true
Generated Narrative: Practitioner PeterPresto Profile: CH Core Practitioner EPR identifier: GLN/7601022050702, urn:oid:2.16.756.5.30.1.123.100.2.1.1/L248519 name: Peter Presto (Official) telecom: ph: 032 333 22 33(Work), peter.presto@arztpraxis.ch
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: PractitionerRole PeterPrestoGruppenpraxis Profile: CH Core PractitionerRole practitioner: Practitioner Peter Presto (official) organization: Organization Gruppenpraxis Olten
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: 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: Specimen Serum-2-pertussis identifier: 48736-12345-75465 accessionIdentifier: 4e88a-12345-dd888 status: Available type: Serum specimen (specimen) subject: Emil Kummer Male, DoB: 2017-05-05 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400004) Collections - Collector Collected[x] * Practitioner Peter Presto (official) 2015-08-16 06:40:17+0000 Containers - Type * Microcapillary blood transfer tube, clot activator (physical object)
Microcapillary blood transfer tube, clot activator (physical object)
Generated Narrative: Specimen ThroatSwab-2-pertussis identifier: 48736-222333-75465 accessionIdentifier: 4e88a-bc987-dd888 status: Available type: Throat swab (specimen) subject: Emil Kummer Male, DoB: 2017-05-05 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400004) receivedTime: 2023-12-01 16:40:17+0000 request: ServiceRequest Respiratory disease screening (procedure) Collections - Collector Collected[x] Method BodySite * Practitioner Peter Presto (official) 2023-12-01 06:40:17+0000 Oral swab (specimen) Entire throat (surface region of neck) (body structure) Containers - Identifier Description Type * 4e88a-bc987-dd888-12345 ESwab 486C tubes Copan General specimen container (physical object) note: Some notes to Sample
Entire throat (surface region of neck) (body structure)
General specimen container (physical object)
Generated Narrative: Specimen Blood-2-pertussis status: Available type: Blood sample subject: Emil Kummer Male, DoB: 2017-05-05 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400004) Collections - Collector Collected[x] BodySite * Practitioner Peter Presto (official) 2015-08-16 06:40:17+0000 Structure of capillary of skin (body structure) Containers - Type * Microcapillary blood transfer tube, ethylene diamine tetraacetic acid (physical object)
Structure of capillary of skin (body structure)
Microcapillary blood transfer tube, ethylene diamine tetraacetic acid (physical object)
Generated Narrative: ServiceRequest 2-pertussis-ServiceRequest Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 status: Active intent: Original Order priority: Urgent code: Laboratory Order orderDetail: Order Control code, New order/service subject: Emil Kummer Male, DoB: 2017-05-05 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400004) requester: PractitionerRole reasonCode: Pertussis suspected (situation)
Respiratory disease screening (procedure)
Generated Narrative: ServiceRequest 2-pertussis-ServiceRequestCBC Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest Respiratory disease screening (procedure) status: Active intent: Original Order priority: Urgent code: Laboratory Order orderDetail: Order Control code, New order/service subject: Emil Kummer Male, DoB: 2017-05-05 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400004) requester: PractitionerRole reasonCode: Pertussis suspected (situation) specimen: Specimen: status = available; type = Blood sample
C reactive protein [Mass/Volume] in Serum or Plasma
Generated Narrative: ServiceRequest 2-pertussis-ServiceRequestCRP Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest Respiratory disease screening (procedure) status: Active intent: Original Order priority: Urgent code: Laboratory Order orderDetail: Order Control code, New order/service subject: Emil Kummer Male, DoB: 2017-05-05 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400004) requester: PractitionerRole reasonCode: Pertussis suspected (situation) specimen: Specimen: identifier = 48736-12345-75465; accessionIdentifier = 4e88a-12345-dd888; status = available; type = Serum specimen (specimen)
Generated Narrative: ServiceRequest 2-pertussis-ServiceRequestAddTest Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest Respiratory disease screening (procedure) status: Active intent: Order priority: Urgent code: Bordetella pertussis and Bordetella parapertussis DNA panel - Nasopharynx orderDetail: Order Control code, change order/service request subject: Emil Kummer Male, DoB: 2017-05-05 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400004) requester: PractitionerRole reasonCode: Pertussis suspected (situation) specimen: Specimen: identifier = 48736-222333-75465; accessionIdentifier = 4e88a-bc987-dd888; status = available; type = Throat swab (specimen); receivedTime = 2023-12-01 16:40:17+0000; note = Some notes to Sample
Bordetella pertussis and Bordetella parapertussis DNA panel - Nasopharynx
Order Control code, change order/service request