2.7 診療シナリオに基づくサンプル

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The 69 years old Pieter van den Heuvel is charged with some serieus deseases in the last few years. In the spring and summer of 2011, Pieter had complains of fatique, dyspnea and even fainting. After visiting his docter, Pieter was referred to the cariologist for further examination. At the hospital a malfunction of the heart valve was diagnosed and replaced. Pieter recovered well in the next 2 moths but probably needs a life time prescription on blood pressure reducing medication. In the summer of 2012, Pieter went again to the doktor for a chest injury after he fell from the stairs. By coincidence, the doctor noticed a suspicious stain on the photo and performed some more 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 left lung. After his recovery, Pieter was submitted in a high risk control group for yearly screening.

In 2013, Peiter was charged with an increasing neck swelling, a stiff neck and difficulty swallowing. Because of breathing problems, Pieter was urgently submitted into the hospital. Surgery was needed to remove the abscess. An upper respiratory infection caused a retropharyngeal abscess in the back of the throat.The surgeons recommanded a tracheotomy during the surgery, so there was less change of complication during the abcess removal. A tracheotomy was intubated before the surgery. After the removal of the retropharyngeal abscess, the trachetomy was extubated as the swelling was reduced and normal breathing was reinstated.

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

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

date: 8-6-2012

Bronchoscopy; several biopts taken from pathological mucosa, right main bronchus biopt send for pathologic analysis. Bronchoscopy because of atelectasis right. X-thorax; increase in atelectasis and pleural liquid. Bronchoscopie; - fluids drained from right main bronchus - pathalogic mucous membrane right bronchus, easily bleeding - Left bronchial system open

date: 18-3-2013

Neck; swelling and redness pretracheal extending to chest. No fluctation, 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.

date: 18-3-2013

Antiobiotic policy with retropharyngeal abcess with prolapse to the mediatinum. No surgical possibility to fully drain the mediatinum.

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

Stop Salbutamol prescription. Continue penicilin and start salbutamol supplementation. Total treatment time is approximatly 6 weeks. In consultation with the IC/anesthesia; intubation. Analyse lower respiratory tract.

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

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

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

Patient 2 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, patient 2 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 optimaly minimized with the therapy in the LUMC. Two severe complications followed the treatment, namely bacterial sepsis (streptococcus aureus) and renal failure. Both were stabilized within a short period through medication (see careplan). Patient 2 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-node and as a final statement: the patient suffers from house dust allergy.