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  1. Care Coordination, dynamic care planning, guidelines/protocol, CQF - clinical quality framework
  2. Emergency Care (Screening)
  3. Pediatric Care (Special needs care)
  4. Medication Management
  5. Clinical Assessment/Problem List


Clinical-on-FHIR Event Friday 20 September 2019, Atlanta Clinician-on-FHIR Event - Clinical Storyboard

Mrs. Patricia (Pat) Chess, a 42-year-old full time office assistant, was involved in a road accident while driving through a busy intersection after work. Her car was struck on the driver’s side by a pick-up truck running a red light.

Pat was trapped in the car for 2 hours while emergency crews worked to extract her from her car. She was conscious and responsive at all times. The paramedics set up IV fluids to treat shock and IV analgesia during her extraction. She was taken by ambulance to the nearest trauma hospital and presented to emergency with multiple injuries.

Pat was assessed by Dr Ernie Medy, the ER physician. On presentation Pat was tachypnoeic with a RR of 29, SpO2 of 93% on 15Lpm O2 via a trauma (non-rebreather) mask. She had decreased breath sounds on the right, a BP of 90/50, in significant pain (9/10), and her GCS was 13.

She had numerous superficial abrasions on her face, arms and chest

Initial trauma “work up” investigations (abdominal, peripheral, and chest and spinal X-rays and CT) showed a closed undisplaced comminuted fracture left mid shaft femur, fracture left ribs 6-7 with

spleen and liver contusions. No fracture vertebrae detected.

She was admitted and prepped for surgery for an open reduction and internal fixation of her femoral fracture and for an exploratory laparotomy for her abdominal injuries.

The preoperative assessment by the anaesthesiologist, Dr Carmen Guess, showed that Pat is a smoker, has a BMI of 34, otherwise, no significant contraindication for general anaesthesia.

She doesn’t participate in any daily physical exercise apart from incidental activity through work and home.


Relevant medical/health history:

  • Smoking history: average 10 cpd/17 years
  • Hypercholesterolaemia: diagnosed in 2009
  • Hypertension: diagnosed in 2010
  • Ischaemic heart disease in 2015
  • She was diagnosed with Type 2 DM in early 2019 and is still working with her diabetes management team to control her blood sugar levels and manage her body weight


Medications:

  • Antihypertensives
  • Cholesterol lowering medication
  • Oral hypoglycaemics
  • Oral contraceptives


Clinician-on-FHIR Tracks

This storyboard uses a common theme for the following Clinician-on-FHIR tracks:

  • Care coordination
  • Emergency care
  • Clinical assessment

Track 1: Dynamic care planning & care coordination

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Clinical scenarios/storyboard

Day 1 post-operative scenario

Subjective:

  • Pat reports pain 4/10 at rest and 8/10 with movement and cough over her chest wall and
  • abdomen. Her left lower limb pain is 3/10 at rest and 7/10 with movement

Objective:

  • Pat is resting in bed with 15 degrees head up, slumped position
  • She is drowsy, but co-operative when awake

Attachments:

  • Indwelling catheter, IV, patient control analgesics line, drains from her laparotomy (liver and spleen) operation

Vital signs:

  • BP 108/62 mmHg, HR 115 bpm RR 25 br/m, mild cyanosis (lips, finger and nail beds)

Respiratory:

  • SpO2 96%, high flow nasal prongs 40 L/min flow, FiO2 0.35
  • Breathing Pattern: shallow, poor basal expansion, no paradoxical movement
  • Cough: Weak, Moist, Ineffective, watery to mucoid sputum
  • Cough and deep breathing limited by pain 8/10
  • Auscultation: Decreased breath sound throughout left lung, coarse crackles left base, fine crackles left base

Neurovascular:

  • Calves soft, non-tender, not swollen
  • Homan’s sign: negative
  • Capillary return R=L=<2sec
  • No pins and needles or numbness

Temperature:

  • 37.6C (99.68F)

Laboratory:

  • Hb 80, haematocrit: 33%, PT 15 seconds; INR: 2.0, RBC: 3.0x1012/L, WBC 3.3 x 109/L, Platelets 140 x 109/L/mcL

Radiology (x-ray chest):

  • Interstitial pulmonary infiltrate left middle and lower lobes

Differential diagnoses:

  • Pulmonary contusion
  • Bronchopneumonia/aspiration pneumonia
  • Pulmonary embolism



Will add a case re: patient in MVA who sustained fractured ribs (6 and 7) and fractured femur with surgery to insert hardware in femur.  Post op- dropped sats, increased SOB, cyanosis, abnormal ABG and increased pain.... will include ED assessments, that confirmed the impression of the fractured ribs and fractured femur.  Will also include clinical assessments and clinical impression, will look at fatty emboli, pneumonia, will end with dx of contusion of the lung.  Will include observation, procedure, condition and clinical impression, diagnostic request, diagnostic impression resources.  Will add the clinical workflow and the resources to be used (including suggested data to be used in the scenario) but to keep enough flexibility for those doing the testing.  (need to be sure to add the demographics, age, gender, etc.... Is this an existing patient in the EHR?  existing data available? - on not... mention the SDoH - but don't need to make it more complex with that data, include a smoking history, or diabetes for the other tracks?)

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