{ "audience" : "student", "createdAt" : "2026-09-25T19:44:58Z", "entries" : [ { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:51.428231+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n22-javier-morales", "learningLevel" : "N22", "panels" : { "assessments" : [ ], "labs" : [ { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "High", "id" : "javier-morales-lab-1", "referenceRange" : "4.0-9.0", "result" : "18.9", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "High", "id" : "javier-morales-lab-2", "referenceRange" : "3.90-4.98", "result" : "6", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "High", "id" : "javier-morales-lab-3", "referenceRange" : "12.0-15.5", "result" : "16.6", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "High", "id" : "javier-morales-lab-4", "referenceRange" : "35-45", "result" : "55", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "Low", "id" : "javier-morales-lab-5", "referenceRange" : "140-400", "result" : "120", "test" : "Platelet Count (1000/mm3)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "Normal", "id" : "javier-morales-lab-6", "referenceRange" : "135-145", "result" : "136", "test" : "Sodium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "Low", "id" : "javier-morales-lab-7", "referenceRange" : "3.5-5.1", "result" : "3.3", "test" : "Potassium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "Normal", "id" : "javier-morales-lab-8", "referenceRange" : "98-107", "result" : "101", "test" : "Chloride (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "Low", "id" : "javier-morales-lab-9", "referenceRange" : "22-29", "result" : "19", "test" : "CO2 (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "High", "id" : "javier-morales-lab-10", "referenceRange" : "70-99", "result" : "168", "test" : "Glucose (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "High", "id" : "javier-morales-lab-11", "referenceRange" : "6-20", "result" : "22", "test" : "Blood Urea Nitrogen (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "High", "id" : "javier-morales-lab-12", "referenceRange" : "0.50-1.00", "result" : "1.4", "test" : "Creatinine (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "Normal", "id" : "javier-morales-lab-13", "referenceRange" : "8.4-10.5", "result" : "8.9", "test" : "Calcium (mg/dL)" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T12:42:00", "flag" : "High", "id" : "javier-morales-lab-14", "referenceRange" : "< 0.04", "result" : "0.06", "test" : "Troponin I" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T13:52:00", "flag" : "Abnormal", "id" : "javier-morales-lab-15", "result" : "Positive", "test" : "COVID-19" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T13:52:00", "flag" : "Abnormal", "id" : "javier-morales-lab-16", "result" : "Positive", "test" : "Influenza A" }, { "category" : "Other", "collectedDateTime" : "2026-09-27T13:52:00", "flag" : "High", "id" : "javier-morales-lab-17", "referenceRange" : "< 2", "result" : "6.6", "test" : "Lactate" }, { "category" : "Other", "collectedDateTime" : "2026-09-27T13:52:00", "flag" : "High", "id" : "javier-morales-lab-18", "referenceRange" : "< 0.5", "result" : "3.8", "test" : "Procalcitonin" } ], "medications" : [ { "doseRouteFrequency" : "2000 mL Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "Lactated Ringer’s", "id" : "javier-morales-med-17", "nextDue" : "2026-09-25T11:52:00", "notes" : "Source due: 9/25/2026 11:52", "orderedBy" : "Erica Chen, MD, Admitting Physician", "orderedDateTime" : "2026-09-25T12:12:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "2 grams Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "Ceftriaxone", "id" : "javier-morales-med-18", "notes" : "IV bolus over 30 minutes (30 mL/kg) Source due: 9/25/2026 11:52 Do not administer from this unresolved source order. Ceftriaxone 2 g order carries fluid-bolus instruction 30 mL/kg. Clarify drug preparation and infusion instructions; do not apply fluid-resuscitation volume to antibiotic.", "orderedBy" : "Erica Chen, MD, Admitting Physician", "orderedDateTime" : "2026-09-25T12:12:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "1500mg Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "Vancomycin", "id" : "javier-morales-med-19", "nextDue" : "2026-09-25T11:52:00", "notes" : "once (now – weight-based 15 mg/kg) Source due: 9/25/2026 11:52 Fixed 1,500 mg dose conflicts with stated 15 mg/kg at documented weight; verify dose and infusion duration.", "orderedBy" : "Erica Chen, MD, Admitting Physician", "orderedDateTime" : "2026-09-25T12:12:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "1000mg Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "Acetaminophen", "id" : "javier-morales-med-20", "nextDue" : "2026-09-25T11:52:00", "notes" : "For fever >101°F Source due: 9/25/2026 11:52 Source orderedDateTime is Hidden; exact timestamp unavailable. Instructor release behavior has not been recreated.", "orderedBy" : "Erica Chen, MD, Admitting Physician", "section" : "Scheduled", "status" : "Active" } ], "notes" : [ { "id" : "javier-morales-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "id" : "javier-morales-provider-review-of-systems", "summary" : "Constitutional (e.g., fever, weight loss) / Notes: 30-year-old Hispanic male, appears stated age, ill-appearing, diaphoretic, in mild respiratory distress. Alert and oriented ×4. Height 5'10\", weight 185 lbs (BMI 26.5). No acute distress when resting.\nHEENT / Notes: Head: Normocephalic, atraumatic. Scalp dry. Eyes: PERRLA, EOMI. Conjunctiva pink, no icterus. No periorbital edema. Ears: Canals clear, TMs pearly gray bilaterally. Nose: Patent, no discharge. Throat: Mucosa pink, no exudates or lesions. Neck supple, no JVD, trachea midline.\nCardiovascular / Notes: HR 118 bpm regular, thready peripheral pulses. BP 102/68 mmHg. Capillary refill 3 seconds. Heart sounds: S1/S2 normal, no murmurs, rubs, or gallops. No pedal edema.\nRespiratory / Notes: RR 24/min, labored. SpO2 94% on room air (improved to 96% on 2L NC). Symmetrical chest rise. Lung sounds: coarse crackles in right lower lobe, diminished in left base. No wheezing. Cough non-productive.\nGastrointestinal / Notes: Soft, non-tender, non-distended. Bowel sounds normoactive in all 4 quadrants. No organomegaly or masses. No rebound or guarding.\nGenitourinary / Notes: No suprapubic tenderness. Foley not indicated at this time. Last void 6 hours ago, small amount, dark yellow.\nMusculoskeletal / Notes: Full ROM all extremities. Strength 5/5 bilaterally. No cyanosis or clubbing. No calf tenderness.\nIntegumentary (skin and/or breast) / Notes: Skin warm, flushed, diaphoretic. Good turgor. No rash, lesions, or pressure injuries. IV site (18g R AC): clean, dry, intact, no redness/swelling.\nNeurological / Notes: Alert, oriented ×4. Speech clear. Pupils 3 mm equal and reactive. Grip strength equal. No focal deficits. Glasgow Coma Scale 15.\nPsychiatric / Notes: Cooperative, anxious but appropriate. Wife present and supportive. No safety concerns.", "type" : "Provider Review Of Systems" }, { "author" : "Erica Chen, MD , Admitting Physician", "dateTime" : "2026-09-25T14:02:00", "id" : "javier-morales-note-1", "summary" : "30-year-old male Javier Morales, previously triaged by RN Diego Ramirez as ESI Level 2. History of confirmed influenza A 4 days ago, now with worsening SOB, dizziness, and fever. Vitals on arrival: HR 118, BP 102/68, RR 24, Temp 100.9°F, SpO2 94% on 2L NC. Lactate resulted at 6.1 mmol/L (critical). Sepsis identified – time zero documented at 0735. Full sepsis bundle initiated: • 30 mL/kg LR bolus (2 L) running • Blood cultures ×2 already drawn by RN Jamal Hayes • Broad-spectrum antibiotics: ceftriaxone 2 g IV + vancomycin 1.5 g IV (weight-based) started • STAT chest X-ray ordered • Continuous cardiac monitoring and q15 min VS • ICU consult placed for possible admission Patient alert and oriented, wife at bedside. Explained sepsis protocol and plan. Will re-evaluate in 30 minutes after fluid bolus. Differential includes post-viral bacterial pneumonia vs viral sepsis.", "type" : "Physician Notes" }, { "author" : "Jamal Hayes , Registered Nurse", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-note-2", "summary" : "Received patient Javier Morales from triage RN Diego Ramirez and assisted to bed #12 in rapid assessment room. Patient changed into hospital gown with assistance (wife present). Connected to continuous cardiac monitor, pulse oximetry, and automatic blood pressure cuff. Vital Signs: HR 118 bpm BP 102/68 mmHg RR 24/min SpO2 96% on 2 L nasal cannula Temp 100.9°F (oral) Monitor/ECG: Sinus tachycardia at 118 bpm, regular rhythm, narrow QRS complexes, no ST changes or ectopy noted. Patient appears ill-appearing, diaphoretic, and in mild respiratory distress, but alert and oriented ×4. Skin warm and flushed. Wife at bedside providing support. Safety measures implemented: Bed in lowest position Side rails up ×2 Call light in reach Fall risk bracelet applied and yellow non-slip socks placed Bed alarm activated IV tubing secured and labeled Two large-bore peripheral IVs inserted (18g R AC, 20g L forearm). labs drawn, collected, and sent to lab per orders.", "type" : "Nursing - Shift" }, { "author" : "Jamal Hayes , Registered Nurse", "dateTime" : "2026-09-25T12:07:00", "id" : "javier-morales-note-3", "summary" : "Dr. Eric Chen is at bedside and entering all STAT orders. Labs (including lactate, blood cultures, CBC, BMP, chest X-ray, etc.) were drawn and just sent to the lab — no results available yet. Current interventions in progress: Patient on continuous cardiac monitor and pulse oximetry 2 large-bore IVs in place Oxygen at 4 L nasal cannula (SpO2 96%) 2 L Lactated Ringer’s bolus started per verbal order Droplet + contact precautions maintained Vital signs being monitored q15 minutes Patient remains alert and oriented ×4, diaphoretic, and in mild respiratory distress. Wife at bedside and updated on the Code Sepsis activation and plan of care", "type" : "Nursing - Event" }, { "author" : "Jamal Hayes , Registered Nurse", "dateTime" : "2026-09-25T12:02:00", "id" : "javier-morales-note-4", "summary" : "Dr. Chen was notified of PT triggering a sepsis alert, now at the bedside assessing PT.", "type" : "Nursing - Event" }, { "id" : "javier-morales-section-current-care-providers", "summary" : "Diego Ramirez | Registered Nurse\nElena Vargas | Registration\nErica Chen, MD | Admitting Physician\nJamal Hayes | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "javier-morales-clarification-8", "summary" : "Source discrepancies: chart age and most narratives say 30; chief complaint says 32. Age 30 retained. Physician note reports lactate 6.1 mmol/L; lab record reports 6.6 at a different, two-days-later timestamp. Both retained, timing requires clarification. Provider Eric Chen in one narrative conflicts with roster Erica Chen; record authors retained.", "type" : "Chart clarification" }, { "id" : "javier-morales-clarification-9", "summary" : "Ceftriaxone 2 g order carries fluid-bolus instruction 30 mL/kg. Clarify drug preparation and infusion instructions; do not apply fluid-resuscitation volume to antibiotic.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-1", "orderText" : "Admit to Medical ICU; x1 (1 time only), 1 time only; Routine; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-2", "orderText" : "Code Sepsis protocol activated; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-3", "orderText" : "Portable chest X-ray STAT; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-4", "orderText" : "Draw Lactate NOW, and in 2 hours and 6 hours.; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-5", "orderText" : "CBC, BMP, and ABG; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-6", "orderText" : "Blood cultures ×2; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-7", "orderText" : "Urine culture; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-8", "orderText" : "Biofire; x1 (1 time only), 1 time only; Routine; Respiratory viral panel Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-9", "orderText" : "Troponin I now and in 3 hours and 6 hours; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:52:00", "id" : "javier-morales-order-10", "orderText" : "Notify MD for any of the following: SBP <90, HR >130, RR >30, SpO2 <92% on 6 L, altered mental status, or lactate not decreasing; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:52", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:52:00", "id" : "javier-morales-order-11", "orderText" : "Continuous cardiac monitoring; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:52", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-12", "orderText" : "Pulse oximetry continuous; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-13", "orderText" : "Vital signs q15 minutes × 4 hours, then q30 minutes; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-14", "orderText" : "Strict input/output monitoring; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-15", "orderText" : "Oxygen via nasal cannula titrate to keep SpO2 ≥94%; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-16", "orderText" : "Bedside glucose q4 hours; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:12", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-17", "orderText" : "Lactated Ringer’s; 2000 mL Intravenous (IV); x1 (1 time only), 1 time only; Scheduled, Stat; Source due: 9/25/2026 11:52", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-18", "orderText" : "Ceftriaxone; 2 grams Intravenous (IV); x1 (1 time only), 1 time only; Scheduled, Stat; IV bolus over 30 minutes (30 mL/kg) Source due: 9/25/2026 11:52 Ceftriaxone 2 g order carries fluid-bolus instruction 30 mL/kg. Clarify drug preparation and infusion instructions; do not apply fluid-resuscitation volume to antibiotic.", "status" : "Held — clarification required" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:12:00", "id" : "javier-morales-order-19", "orderText" : "Vancomycin; 1500mg Intravenous (IV); x1 (1 time only), 1 time only; Scheduled, Stat; once (now – weight-based 15 mg/kg) Source due: 9/25/2026 11:52", "status" : "Active" }, { "author" : "Erica Chen, MD, Admitting Physician", "category" : "Pharmacy", "id" : "javier-morales-order-20", "orderText" : "Acetaminophen; 1000mg Intravenous (IV); x1 (1 time only), 1 time only; Scheduled, Stat; For fever >101°F Source due: 9/25/2026 11:52 Source dateTime is Hidden; exact timestamp unavailable. Instructor release behavior has not been recreated.", "status" : "Active" } ], "overview" : { "height" : "70 in / 177.8 cm", "isolationIndicator" : "Standard", "religion" : "", "weightKg" : 83.9 }, "vitals" : [ { "bloodPressure" : "102/68", "dateTime" : "2026-09-25T12:02:00", "heartRate" : 118, "id" : "javier-morales-vital-1", "oxygenDevice" : "Nasal Cannula", "respiratoryRate" : 24, "spo2" : "96", "temperature" : "100.9 °F (38 °C), 38 °C Oral" } ] }, "patient" : { "admitDateTime" : "2026-09-25T11:52:00", "admittingDiagnosis" : "Sepsis in the setting of influenza A", "allergies" : [ ], "attending" : "Erica Chen, MD, Admitting Physician", "chartDisplayName" : "Morales, Javier", "codeStatus" : "", "dob" : "8/2/XX", "history" : { "chiefComplaint" : "A 32-year-old male with no significant past medical history presents to the ED with 4 days of influenza-like illness. Patient reports sudden onset of fever, chills, body aches, dry cough, and fatigue after exposure to a sick coworker. He tested positive for Influenza A via rapid test at urgent care 3 days ago and was advised to rest and hydrate at home. Over the last 12–18 hours, symptoms have worsened significantly, with new-onset shortness of breath on exertion, dizziness on standing, and subjective fever. He denies chest pain, palpitations, abdominal pain, nausea, vomiting, diarrhea, or urinary symptoms. No recent travel, no known COVID exposure, and no vomiting or diarrhea. He has been taking acetaminophen and ibuprofen as needed with only mild relief. Patient appears ill but alert and oriented. Accompanied by wife who confirms the rapid decline in the last day. Pertinent Positives: Recent confirmed influenza, progressive dyspnea, dizziness, fever Pertinent Negatives: No chest pain, no hemoptysis, no rash, no neck stiffness, no focal weakness", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 30 years", "Nutritional Screening / Last Bowel Movement Days: 0", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment" ] }, "mrn" : "567894326", "sex" : "Male", "simulatedFullName" : "Javier Morales", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "javier-morales-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2026-09-25T11:57:00", "sourcePath" : "DocuCare instructor chart: Javier Morales", "title" : "Captured chart" } ], "subtitle" : "N22 practice record", "tags" : [ "N22", "DocuCare migration" ], "title" : "Javier Morales" }, "packageId" : "docucare-n22-javier-morales-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated educational record only. Not for clinical care. Review the chart and faculty directions before practice." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "n22-javier-morales", "instructions" : "Open the assigned patient chart. Confirm name, DOB and MRN; review allergies, notes, vitals, labs, orders and the MAR. Discuss missing or conflicting information with faculty. Held and discontinued medications are for review and are not active administration tasks. Scenario dates are historical. Follow your faculty directions.", "title" : "Javier Morales" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:51.428231+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n22-priya-patel", "learningLevel" : "N22", "panels" : { "assessments" : [ ], "labs" : [ { "category" : "Other", "collectedDateTime" : "2026-09-25T11:50:00", "flag" : "Unverified", "id" : "priya-patel-lab-1", "result" : "7.32", "test" : "pH" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:50:00", "flag" : "Unverified", "id" : "priya-patel-lab-2", "result" : "32", "test" : "Paco2" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:50:00", "flag" : "Unverified", "id" : "priya-patel-lab-3", "result" : "78", "test" : "Pao2" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:50:00", "flag" : "Unverified", "id" : "priya-patel-lab-4", "result" : "18", "test" : "Hco3" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:50:00", "flag" : "Unverified", "id" : "priya-patel-lab-5", "result" : "-6", "test" : "BE" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:50:00", "flag" : "Unverified", "id" : "priya-patel-lab-6", "result" : "96%", "test" : "SaO2" } ], "medications" : [ { "doseRouteFrequency" : "1000 Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "Normal saline", "id" : "priya-patel-med-22", "notes" : "Source due: 9/25/2026 12:16 Do not administer from this unresolved source order. Source saline bolus dose is 1000 without a volume unit or duration. Prior EMS 500 mL bolus does not establish this order; clarify.", "orderedBy" : "Malik Thompson, MD", "orderedDateTime" : "2026-09-25T12:16:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "50 Intravenous (IV) x4 (4 times only), 4 times only", "drug" : "Fentanyl", "id" : "priya-patel-med-23", "notes" : "Anxiety/Pain Source due: PRN Do not administer from this unresolved source order. Source Fentanyl dose is a bare number without units or a repeat interval; confirm dose units, interval and procedural sedation instructions. No units inferred.", "orderedBy" : "Malik Thompson, MD", "orderedDateTime" : "2026-09-25T12:16:00", "section" : "PRN", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "1 Intravenous (IV) x2 (2 times only), 2 times only", "drug" : "Midazolam", "id" : "priya-patel-med-24", "notes" : "Sedation Source due: PRN Do not administer from this unresolved source order. Source Midazolam dose is a bare number without units or a repeat interval; confirm dose units, interval and procedural sedation instructions. No units inferred.", "orderedBy" : "Malik Thompson, MD", "orderedDateTime" : "2026-09-25T12:16:00", "section" : "PRN", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "100 ml per hr Intravenous (IV) cont.", "drug" : "Normal saline", "id" : "priya-patel-med-25", "nextDue" : "2026-09-25T12:16:00", "notes" : "Source due: 9/25/2026 12:16", "orderedBy" : "Malik Thompson, MD", "orderedDateTime" : "2026-09-25T12:16:00", "section" : "Scheduled", "status" : "Active" } ], "notes" : [ { "id" : "priya-patel-allergy", "summary" : "Pollen | Environmental | Urticaria | Causes rhinorrhea and itching; takes OTC loratadine as needed | Jessica Ramirez | 9/25/2026 12:00", "type" : "Allergy documentation" }, { "id" : "priya-patel-provider-review-of-systems", "summary" : "Constitutional (e.g., fever, weight loss) / Notes: No fever, chills, or night sweats. Reports usual third-trimester fatigue. Appears diaphoretic and pale.\nHEENT / Notes: Denies headache, vision changes, nasal congestion, sore throat.\nCardiovascular / Notes: Crushing substernal chest pain (10/10) radiating to upper back, lightheadedness. Denies prior similar episodes except brief one in last pregnancy.\nRespiratory / Notes: Positive for profound shortness of breath and air hunger. Denies cough, wheezing, hemoptysis.\nGastrointestinal / Notes: Denies nausea, vomiting, diarrhea, constipation, abdominal pain beyond mild diffuse tenderness. Appetite normal until today.\nGenitourinary / Notes: Denies dysuria, urgency, frequency, vaginal bleeding, leakage of fluid, or contractions.\nMusculoskeletal / Notes: Positive for upper back pain (radiating from chest). Denies lower back pain, joint swelling, or muscle aches.\nIntegumentary (skin and/or breast) / Notes: Denies rashes or pruritus beyond usual pregnancy-related dry skin.\nNeurological / Notes: Denies syncope, focal weakness, numbness, tingling, or confusion. Appears alert but anxious.\nPsychiatric / Notes: Denies anxiety or depression beyond situational distress.\nEndocrine / Notes: Denies polyuria, polydipsia, heat/cold intolerance.\nHematologic/Lymphatic / Notes: Denies easy bruising or bleeding.\nAllergic/Immunologic / Notes: Seasonal allergic rhinitis (environmental pollen).\nAdditional Notes / Notes: Denies contractions, decreased fetal movement (reports good movement earlier today), vaginal bleeding, or rupture of membranes. Gestational diabetes mellitus in previous pregnancy (diet-controlled, resolved postpartum; postpartum 2-hour GTT normal)", "type" : "Provider Review Of Systems" }, { "id" : "priya-patel-family-health-history", "summary" : "Disease/Condition / Disease/Condition: Diabetes/Pre-Diabetes/Metabolic Syndrome\nType / Type: 2\nFamily Member / Family Member: Mother\nAge at Diagnosis / Age at Diagnosis: 60 years and older", "type" : "Family Health History" }, { "id" : "priya-patel-serial-weights", "summary" : "2026-09-25T11:50:00: 170 lb (77 kg), 77 kg Patient statement\n2026-09-25T12:12:00: 174 lb (79 kg), 79 kg Bed scale", "type" : "Weight history" }, { "author" : "Malik Thompson , MD", "dateTime" : "2026-09-25T12:15:00", "id" : "priya-patel-note-1", "summary" : "General: Ill-appearing, diaphoretic, pale HEENT: Dry mucous membranes CV: Tachycardic, regular, distant heart sounds Lungs: Clear, good air movement, tachypneic Abdomen: Gravid, soft, mild diffuse tenderness, fundal height 26 cm Ext: Cool, thready pulses, no edema Neuro: Lethargic but opens eyes to voice Fetal monitoring initiated: FHR 130 bpm with minimal variability and late decelerations.", "type" : "Emergency Room Physician" }, { "author" : "Erica Pham , Registered Nurse", "dateTime" : "2026-09-25T12:15:00", "id" : "priya-patel-note-2", "summary" : "Narrow-complex regular tachycardia at 248 bpm, no P waves - MD Thompson at bedside.", "type" : "Nursing - Event" }, { "author" : "Maya Rodriguez , Registered Nurse", "dateTime" : "2026-09-25T12:10:00", "id" : "priya-patel-note-3", "summary" : "Patient returned from L&D. Moaning, eyes closed, responds to voice, skin mottled. Tech connecting PT to monitor, MD paged to come to bedside.", "type" : "Nursing - Event" }, { "author" : "Vanessa Ortiz , Admitting Physician", "dateTime" : "2026-09-25T12:00:00", "id" : "priya-patel-note-4", "summary" : "Patient's symptoms do not correlate with pre-term labor, appear primarily cardiac → patient should be managed in ED with cardiology involvement. Patient transferred back to ED resuscitation bay at 14:32 with continuous monitoring.", "type" : "Physician Notes" }, { "author" : "Jessica Ramirez , Registered Nurse", "dateTime" : "2026-09-25T11:55:00", "id" : "priya-patel-note-5", "summary" : "Patient received in L&D triage in distress. Continues to report severe palpitations, 10/10 substernal crushing chest pain radiating to upper back, profound dyspnea (speaking 2-3 words only). Denies bleeding, fluid leakage, contractions. Fetal heart rate 135 bpm with minimal variability. Rapid assessment: pale, diaphoretic, cool/clammy.", "type" : "Nursing - Event" }, { "author" : "Erica Pham , Registered Nurse", "dateTime" : "2026-09-25T11:51:00", "id" : "priya-patel-note-6", "summary" : "Patient wheeled directly from ambulance bay to L&D per OB protocol for pregnant patients >20 weeks with any complaint. ED physician (Dr. Malik Thompson) briefly at bedside, notes obvious tachycardia on monitor, agrees with transfer to L&D for primary management.", "type" : "Nursing - Transfer" }, { "author" : "Mike Johnson , Paramedic Report", "dateTime" : "2026-09-25T11:28:00", "id" : "priya-patel-note-7", "summary" : "Chief Complaint (per EMS): 29-year-old G2P1 at 26 weeks of gestation with sudden-onset severe palpitations, crushing chest pain radiating to back, profound shortness of breath, and lightheadedness starting ~40 minutes prior to arrival while at work. Patient found at workplace in obvious distress: pale, diaphoretic, clutching chest, speaking only 2-3 words at a time (“heart racing… can’t breathe… pain”). Monitor shows narrow-complex tachycardia at ~240-250 bpm. O2 sat 90-92% on room air → improved to 96% on NRB at 15 L. Patient reports 26 weeks pregnant → decision made to transport directly to L&D triage per protocol. No manual BP obtained en route (thready pulses, monitor unable to capture). IV access established x1 (18ga left AC). Normal saline bolus 500 mL given. Fetal heart tones auscultated. Patient remains alert but anxious.", "type" : "Miscellaneous" }, { "id" : "priya-patel-section-immunizations", "summary" : " Birth to Adult Immunizations: Influenza, Td/Tdap, Varicella, MMR 1, MMR 2, Rubella, Polio, Hepatitis B\n Titers: N/A\n9/25/2026 11:50 | Birth to Adult Immunizations: Influenza, Td/Tdap, Varicella, MMR 1, MMR 2, Rubella, Polio, Hepatitis B Titers: N/A", "type" : "Immunizations" }, { "id" : "priya-patel-section-current-care-providers", "summary" : "Erica Pham | Registered Nurse\nJessica Ramirez | Registered Nurse\nLinh Pham | Consulting Physician\nMalik Thompson | MD\nMaya Rodriguez | Registered Nurse\nMike Johnson | Paramedic Report\nVanessa Ortiz | Admitting Physician", "type" : "Current Care Providers" }, { "id" : "priya-patel-section-relevant-history", "summary" : "Relevant Medical History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) Help - What Relevant Medical History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) means / Maternal History / Gravida: 2\nRelevant Medical History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) Help - What Relevant Medical History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) means / Maternal History / Number of Term Births: 1\nRelevant Medical History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) Help - What Relevant Medical History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) means / Maternal History / Number of Preterm Births: 0\nRelevant Medical History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) Help - What Relevant Medical History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) means / Maternal History / Number of Abortions: 0\nRelevant Medical History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) Help - What Relevant Medical History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) means / Maternal History / Number of Living Children: 1\nRelevant Medical History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) Help - What Relevant Medical History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) means / Maternal History / Hx of Abnormal Ultrasound: No\nSocial History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) / Prenatal Care / Started Prenatal Care: 9/25/2026\nSocial History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) / Alcohol Use / Alcohol Consumption During Pregnancy: No\nSocial History (Last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50) / Drug Use / Illicit Drug Use During Pregnancy: No", "type" : "Relevant History" }, { "id" : "priya-patel-section-intrapartum", "summary" : "Intrapartum Maternal Antibiotic Therapy / Other Medications Given\nRelevant Medical History Help - What Relevant Medical History means / Past Medical History last updated by Jessica Ramirez, Registered Nurse on 9/25/2026 11:50\nBMP | x1 (1 time only), 1 time only | N/A | N/A\nCardiology consult | x1 (1 time only), 1 time only | N/A | N/A\nCBC with differential | x1 (1 time only), 1 time only | N/A | N/A\nContinuous cardiac telemetry | cont. | N/A | N/A\nContinuous external fetal heart rate monitoring NOW | cont. | N/A | N/A\nFentanyl | x4 (4 times only), 4 times only | N/A | Anxiety/Pain\nHigh Sensitivity Troponin x3 | q1h x3 (Every 1 hour, 3 times only), Every 1 hour, 3 times only | N/A | N/A\nLactic acid | x1 (1 time only), 1 time only | N/A | N/A\nLeft uterine displacement (manual or wedge) | cont. | N/A | N/A\nMagnesium level | x1 (1 time only), 1 time only | N/A | N/A\nMidazolam | x2 (2 times only), 2 times only | N/A | Sedation\nNormal saline | cont. | N/A | N/A\nNormal saline | x1 (1 time only), 1 time only | N/A | N/A\nOB/GYN consult | x1 (1 time only), 1 time only | N/A | N/A\nObtain consent for cardioversion, sedation, and transfusion | x1 (1 time only), 1 time only | N/A | N/A\nOxygen via non-rebreather mask titrate to maintain SpO2 ≥94% (or higher per OB/fetal needs) | x1 (1 time only), 1 time only | N/A | N/A\nPhosphorus | x1 (1 time only), 1 time only | N/A | N/A\nPortable chest X-ray | x1 (1 time only), 1 time only | N/A | (single view, abdominal shielding)\nPrepare defibrillator pads and crash cart at bedside | x1 (1 time only), 1 time only | N/A | N/A\nPrepare perimortem C-section kit at bedside | x1 (1 time only), 1 time only | N/A | N/A\nPT/INR, PTT | x1 (1 time only), 1 time only | N/A | N/A\nSTAT 12-lead EKG NOW | x1 (1 time only), 1 time only | N/A | N/A\nSynchronized cardioversion if unstable | x1 (1 time only), 1 time only | N/A | N/A\nTSH, free T4 | x1 (1 time only), 1 time only | N/A | N/A\nType and screen | x1 (1 time only), 1 time only | N/A | N/A\nVenous Blood Gas | x1 (1 time only), 1 time only | N/A | N/A\nVital signs q5min until stable | x1 (1 time only), 1 time only | N/A | N/A", "type" : "Intrapartum" }, { "id" : "priya-patel-section-delivery", "summary" : "Maternal / Post Birth Maternity History / Gravida: 2\nMaternal / Post Birth Maternity History / Number of Term Births: 1\nMaternal / Post Birth Maternity History / Number of Preterm Birth: 0\nMaternal / Post Birth Maternity History / Number of Abortions: 0\nMaternal / Post Birth Maternity History / Number of Living Children: 1", "type" : "Delivery" }, { "id" : "priya-patel-clarification-17", "summary" : "Source saline bolus dose is 1000 without a volume unit or duration. Prior EMS 500 mL bolus does not establish this order; clarify.", "type" : "Chart clarification" }, { "id" : "priya-patel-clarification-18", "summary" : "Source Fentanyl dose is a bare number without units or a repeat interval; confirm dose units, interval and procedural sedation instructions. No units inferred.", "type" : "Chart clarification" }, { "id" : "priya-patel-clarification-19", "summary" : "Source Midazolam dose is a bare number without units or a repeat interval; confirm dose units, interval and procedural sedation instructions. No units inferred.", "type" : "Chart clarification" }, { "id" : "priya-patel-clarification-20", "summary" : "Source timeline has a literal transfer time 14:32 inside a note timestamped relative to chart launch. Gestation is 26 weeks in EMS narrative; third-trimester language elsewhere conflicts. Preserve 26-week clinical narrative; clarify exact gestational day and intended event timing. No structured assessment entries were present.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-1", "orderText" : "Vital signs q5min until stable; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-2", "orderText" : "Oxygen via non-rebreather mask titrate to maintain SpO2 ≥94% (or higher per OB/fetal needs); x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-3", "orderText" : "STAT 12-lead EKG NOW; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-4", "orderText" : "Portable chest X-ray; x1 (1 time only), 1 time only; Stat; (single view, abdominal shielding) Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-5", "orderText" : "CBC with differential; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-6", "orderText" : "Left uterine displacement (manual or wedge); cont.; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-7", "orderText" : "Synchronized cardioversion if unstable; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-8", "orderText" : "Prepare perimortem C-section kit at bedside; x1 (1 time only), 1 time only; Routine; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-9", "orderText" : "Obtain consent for cardioversion, sedation, and transfusion; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-10", "orderText" : "BMP; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-11", "orderText" : "Magnesium level; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-12", "orderText" : "Phosphorus; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-13", "orderText" : "Lactic acid; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-14", "orderText" : "High Sensitivity Troponin x3; q1h x3 (Every 1 hour, 3 times only), Every 1 hour, 3 times only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-15", "orderText" : "TSH, free T4; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-16", "orderText" : "PT/INR, PTT; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-17", "orderText" : "Type and screen; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-18", "orderText" : "Venous Blood Gas; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Not specified", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-19", "orderText" : "Prepare defibrillator pads and crash cart at bedside; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Nursing", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-20", "orderText" : "Continuous external fetal heart rate monitoring NOW; cont.; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-21", "orderText" : "Continuous cardiac telemetry; cont.; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-22", "orderText" : "Normal saline; 1000 Intravenous (IV); x1 (1 time only), 1 time only; Scheduled, Stat; Source due: 9/25/2026 12:16 Source saline bolus dose is 1000 without a volume unit or duration. Prior EMS 500 mL bolus does not establish this order; clarify.", "status" : "Held — clarification required" }, { "author" : "Malik Thompson, MD", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-23", "orderText" : "Fentanyl; 50 Intravenous (IV); x4 (4 times only), 4 times only; PRN, Stat; Anxiety/Pain Source due: PRN Source Fentanyl dose is a bare number without units or a repeat interval; confirm dose units, interval and procedural sedation instructions. No units inferred.", "status" : "Held — clarification required" }, { "author" : "Malik Thompson, MD", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-24", "orderText" : "Midazolam; 1 Intravenous (IV); x2 (2 times only), 2 times only; PRN, Stat; Sedation Source due: PRN Source Midazolam dose is a bare number without units or a repeat interval; confirm dose units, interval and procedural sedation instructions. No units inferred.", "status" : "Held — clarification required" }, { "author" : "Malik Thompson, MD", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-25", "orderText" : "Normal saline; 100 ml per hr Intravenous (IV); cont.; Cont. Infusion; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Referrals", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-26", "orderText" : "OB/GYN consult; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" }, { "author" : "Malik Thompson, MD", "category" : "Referrals", "dateTime" : "2026-09-25T12:16:00", "id" : "priya-patel-order-27", "orderText" : "Cardiology consult; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:16", "status" : "Active" } ], "overview" : { "height" : "65 in / 165.1 cm", "isolationIndicator" : "Standard", "religion" : "Hindu", "weightKg" : 78.5 }, "vitals" : [ { "dateTime" : "2026-09-25T11:50:00", "id" : "priya-patel-vital-1", "respiratoryRate" : 30 }, { "dateTime" : "2026-09-25T11:56:00", "id" : "priya-patel-vital-2" }, { "bloodPressure" : "78/46", "dateTime" : "2026-09-25T12:12:00", "heartRate" : 248, "id" : "priya-patel-vital-3", "oxygenDevice" : "Room Air", "respiratoryRate" : 32, "spo2" : "90", "temperature" : "98.2 °F (37 °C), 37 °C" } ] }, "patient" : { "admitDateTime" : "2026-09-25T11:50:00", "admittingDiagnosis" : "Unstable supraventricular tachycardia in pregnancy", "allergies" : [ { "id" : "allergy-bbe3fbaf3edcdda5", "reaction" : "Urticaria", "severity" : "Not documented", "substance" : "Pollen" } ], "attending" : "Vanessa Ortiz, Admitting Physician", "chartDisplayName" : "Patel, Priya", "codeStatus" : "Full Code", "dob" : "4/12/XX", "history" : { "chiefComplaint" : "", "pastMedicalHistory" : [ "Maternal History / Gravida: 2", "Maternal History / Number of Term Births: 1", "Maternal History / Number of Preterm Births: 0", "Maternal History / Number of Abortions: 0", "Maternal History / Number of Living Children: 1", "Maternal History / Hx of Abnormal Ultrasound: No", "General Medical History / Disease/Condition / : Allergic rhinitis", "General Medical History / Active: Active", "General Medical History / Disease/Condition / : Asthma", "General Medical History / Resolved: Resolved", "General Medical History / Disease/Condition / : Gestational diabetes", "General Medical History / Resolved: Resolved", "Transfusion History / Previous Blood Transfusion?: No", "Transfusion History / Does Patient Know His/Her Blood Type?: No", "Pain History / History of Chronic Pain?: No" ], "pastSurgicalHistory" : [ "Previous Surgical Procedures: No prior surgical history" ], "socialHistory" : [ "Age: 29 years", "Home Situation / Patient Living Situation: Home", "Home Situation / Lives With: Other family member", "Education / Highest Grade Completed: College", "Education / Able to Read?: Yes", "Education / Able to Write?: Yes", "Prenatal Care / Started Prenatal Care Days: 0", "Prenatal Care / Started Prenatal Care Relative To Timing Based On: before student launches assignment", "Nicotine Use / Cigarettes: Nonsmoker", "Nicotine Use / Chewing Tobacco: Nonuser", "Nicotine Use / Cigars/Pipe: Nonsmoker", "Nicotine Use / Is patient exposed to second-hand smoke?: No", "Alcohol Use / Alcohol Consumption During Pregnancy: No", "Alcohol Use / Has Patient Ever Been Diagnosed With or Treated for Alcohol Abuse?: No", "Drug Use / Illicit Drug Use During Pregnancy: No", "Drug Use / Has Patient Ever Been Diagnosed With or Treated for Drug Abuse?: No", "Drug Use / Drug Screening: N/A", "Violence Screening / Does Patient Feel Safe at Home?: Yes", "Violence Screening / Does Patient Feel Safe in Current Environment (Work, School, etc.)?: Yes", "Violence Screening / Has Anyone Ever Hurt Patient Emotionally, Physically, or Sexually?: No", "Nutritional Screening / Decreased Appetite?: No", "Nutritional Screening / Does patient have diabetes?: No", "Nutritional Screening: Vegetarian", "Nutritional Screening / Stool Frequency: daily", "Nutritional Screening / Stool Description: Loose", "Nutritional Screening / Last Bowel Movement Days: 1", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment", "Exercise Screening / Exercise Frequency: Daily", "Exercise Screening / Duration of Exercise: 30 mins", "Exercise Screening / Intensity: Mild", "Exercise Screening / Type(s): walking since she became pregnant", "Mental Health Screening / Does Patient Have Frequent Feelings of Hopelessness/Helplessness?: No", "Mental Health Screening / Does Patient Have Thoughts of Harming Self?: No", "Sexual Activity / Sexually Active?: No", "Sexual Activity / Ever Treated for a Sexually Transmitted Disease?: No" ] }, "mrn" : "86166002", "sex" : "Female", "simulatedFullName" : "Priya Patel", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "priya-patel-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2026-09-25T12:00:00", "sourcePath" : "DocuCare instructor chart: Priya Patel", "title" : "Captured chart" } ], "subtitle" : "N22 practice record", "tags" : [ "N22", "DocuCare migration" ], "title" : "Priya Patel" }, "packageId" : "docucare-n22-priya-patel-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated educational record only. Not for clinical care. Review the chart and faculty directions before practice." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "n22-priya-patel", "instructions" : "Open the assigned patient chart. Confirm name, DOB and MRN; review allergies, notes, vitals, labs, orders and the MAR. Discuss missing or conflicting information with faculty. Held and discontinued medications are for review and are not active administration tasks. Scenario dates are historical. Follow your faculty directions.", "title" : "Priya Patel" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:51.428231+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n22-sabina-vasquez", "learningLevel" : "N22", "panels" : { "assessments" : [ ], "labs" : [ { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:02:00", "flag" : "Normal", "id" : "sabina-vasquez-lab-1", "referenceRange" : "136-145", "result" : "140", "test" : "Sodium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:02:00", "flag" : "Normal", "id" : "sabina-vasquez-lab-2", "referenceRange" : "3.4-4.7", "result" : "4.0", "test" : "Potassium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:02:00", "flag" : "Normal", "id" : "sabina-vasquez-lab-3", "referenceRange" : "90-110", "result" : "100", "test" : "Chloride (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:02:00", "flag" : "Normal", "id" : "sabina-vasquez-lab-4", "referenceRange" : "20-28", "result" : "24", "test" : "CO2 (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:02:00", "flag" : "Normal", "id" : "sabina-vasquez-lab-5", "referenceRange" : "70-110", "result" : "80", "test" : "Glucose (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:02:00", "flag" : "Normal", "id" : "sabina-vasquez-lab-6", "referenceRange" : "5-18", "result" : "10", "test" : "Blood Urea Nitrogen (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T12:02:00", "flag" : "Normal", "id" : "sabina-vasquez-lab-7", "referenceRange" : "0.3-0.7", "result" : "0.6", "test" : "Creatinine (mg/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T12:02:00", "flag" : "High", "id" : "sabina-vasquez-lab-8", "referenceRange" : "5.5-15.5", "result" : "20", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T12:02:00", "flag" : "Normal", "id" : "sabina-vasquez-lab-9", "referenceRange" : "12.0-15.5", "result" : "12.4", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T12:02:00", "flag" : "Normal", "id" : "sabina-vasquez-lab-10", "referenceRange" : "35-45", "result" : "37.4", "test" : "Hematocrit (%)" } ], "medications" : [ { "doseRouteFrequency" : "11.4 mg Oral (PO) x1 (1 time only), 1 time only", "drug" : "dexamethasone (oral)", "id" : "sabina-vasquez-med-10", "nextDue" : "2026-09-25T12:02:00", "notes" : "Source due: 9/25/2026 12:02", "orderedBy" : "Martha Harris, Admitting Physician", "orderedDateTime" : "2026-09-25T12:02:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "190 mg Oral (PO) x1 (1 time only), 1 time only", "drug" : "azithromycin", "id" : "sabina-vasquez-med-11", "notes" : "Azithromycin 190 mg (10 mg/kg) orally today X 1 day, followed by 95 mg (5 mg/kg) orally once per day x 4 days.", "orderedBy" : "Martha Harris, Admitting Physician", "orderedDateTime" : "2026-09-25T12:02:00", "section" : "Scheduled", "status" : "Pending" }, { "doseRouteFrequency" : "950 mg Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "magnesium sulfate (injection)", "id" : "sabina-vasquez-med-12", "nextDue" : "2026-09-25T12:02:00", "notes" : "over 20 minutes if no improvement after 3 albuterol/ipratropium doses and glucocorticoids Source due: 9/25/2026 12:02", "orderedBy" : "Martha Harris, Admitting Physician", "orderedDateTime" : "2026-09-25T12:02:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "2.85 mg Inhalation cont.", "drug" : "albuterol sulfate", "id" : "sabina-vasquez-med-13", "lastGiven" : "2026-09-25T12:02:00", "notes" : "Albuterol nebulized + ipratropium bromide 250 mcg q20min ×3 (or short-term continuous for first hour) Source due: cont. Do not administer from this unresolved source order. Structured albuterol frequency is continuous, but directions offer q20min ×3 or short-term continuous plus ipratropium. Continuous mg/hr rate is absent. Clarify intended regimen; do not interpret 2.85 mg as a continuous hourly rate.", "orderedBy" : "Martha Harris, Admitting Physician", "orderedDateTime" : "2026-09-25T12:12:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "240 mg Oral (PO) every 4–6 hours PRN fever >38.6°C", "drug" : "acetaminophen", "id" : "sabina-vasquez-med-14", "notes" : "Acetaminophen 240 mg (10-15 mg/kg/dose) PO every 4-6 hours as needed for fever > 38.6 C (101.5 F). Source due: PRN", "orderedBy" : "Martha Harris, Admitting Physician", "orderedDateTime" : "2026-09-25T12:02:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "61 ml per hr Intravenous (IV) cont.", "drug" : "D5 1/2 NS + 20 mEq KCl per liter", "id" : "sabina-vasquez-med-15", "lastGiven" : "2026-09-25T12:02:00", "notes" : "Source due: cont.", "orderedBy" : "Martha Harris, Admitting Physician", "orderedDateTime" : "2026-09-25T12:02:00", "section" : "Scheduled", "status" : "Active" } ], "notes" : [ { "id" : "sabina-vasquez-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "id" : "sabina-vasquez-provider-review-of-systems", "summary" : "Constitutional (e.g., fever, weight loss) / Notes: Positive for decreased activity and fatigue. Negative for fever, chills, night sweats, or weight loss.\nHEENT / Notes: Negative for redness, discharge, or vision changes. Positive for runny nose and cough from recent upper respiratory infection (3 days). Negative for ear pain, sore throat, or difficulty swallowing.\nCardiovascular / Notes: Negative for chest pain, palpitations, or cyanosis.\nRespiratory / Notes: Positive for wheezing, cough, shortness of breath, and increased work of breathing with accessory muscle use. Negative for hemoptysis or stridor.\nGastrointestinal / Notes: Negative for vomiting, diarrhea, and abdominal pain. Positive for decreased appetite.\nGenitourinary / Notes: Negative for dysuria, frequency, or hematuria.\nMusculoskeletal / Notes: Negative for joint pain, swelling, or trauma.\nIntegumentary (skin and/or breast) / Notes: Negative for rash, lesions, or pruritus.\nNeurological / Notes: Negative for headache, seizures, or altered mental status\nPsychiatric / Notes: Negative for behavioral changes or irritability beyond discomfort from breathing difficulty.\nAllergic/Immunologic / Notes: History of asthma; no new allergies or recurrent infections noted.\nAdditional Notes / Notes: ROS obtained from mother. Pertinent positives limited to recent URI symptoms and acute respiratory complaints consistent with moderate asthma exacerbation. All other systems negative.", "type" : "Provider Review Of Systems" }, { "id" : "sabina-vasquez-family-health-history", "summary" : "Disease/Condition / Disease/Condition: Hypertension\nFamily Member / Family Member: Maternal Grandmother\nAge at Diagnosis / Age at Diagnosis: Unknown", "type" : "Family Health History" }, { "id" : "sabina-vasquez-mar", "summary" : "albuterol sulfate 2 puffs Inhalation | x1 (1 time only), 1 time only | 9/24/2026 12:02 | Albuterol MDI with spacer.", "type" : "Home medication history" }, { "author" : "Nancy Wright , Registered Nurse", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-note-1", "summary" : "Sabina Vasquez is a 5-year-old Hispanic female presenting in respiratory distress with wheezing and rales throughout lungs. She has had an upper respiratory infection for several days and developed a fever early this morning. Sabina lives at home with her parents and two younger brothers. Her mother reports that she has a history of asthma with several exacerbations requiring use of an albuterol metered-dose inhaler at home. Assessment completed and provider notified. Developmentally appropriate for age, immunizations up to date.", "type" : "Nursing - Admission" }, { "author" : "Martha Harris , Admitting Physician", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-note-2", "summary" : "Sabina Vasquez is a 5-year-old Hispanic female presenting to the emergency room in moderate respiratory distress. Upon assessment, patient has mild substernal retractions, a productive cough, wheezing and rales throughout all lung fields, and an oxygen saturation of 90% on room air. Patient has had an upper respiratory infection for a few days and then developed a fever of 102.2F (39.0C) and shortness of breath this morning. Sabina has a history of asthma with several exacerbations requiring use of an albuterol metered-dose inhaler at home. In the emergency room, she was placed on oxygen via nasal cannula at 2 L/min. She received a 380-mL bolus of normal saline and an albuterol nebulizer treatment 2 hours ago. This improved her oxygen saturation to 94%. Allergies/Reactions: No known allergies Immunizations: Up to date Medications: Albuterol MDI with spacer. Pregnancy and Birth: Vaginal delivery at 39 weeks/gestation. Birth weight: 3250 grams. Birth Length: 51 cm. No medical problems. Nutrition and Feeding: Breast fed for 6 months. No feeding or dietary problems. Weight: 19 kg. Height: 119 cm. Normal growth as expected for age. Development: Has met all developmental milestones. Family History: Maternal grandmother has a history of hypertension. Social History: Parents are married. Sabina was born in Mexico City and her family moved here 2 years ago. Sabina lives at home with her parents and two younger brothers, one cat. Sabina’s mother is at the bedside and speaks broken English. Previous Medical Problems: Diagnosed with asthma at age 3. Per mom, Sabina gets a lot of colds in the winter and has a history of multiple ear infections as an infant and toddler. During the last 2 months, she has been seen several times at her primary care provider’s office for asthma symptoms and upper respiratory infections. Diagnosis: Pneumonia Radiology: Chest x-ray revealed right lower lobe pneumonia with effusion. Abnormal Labs: - White Blood Cell Count: 20 (5.5-15.5 x 1000 cells/mm3) - Hemoglobin: 12.4 (11.5-15.5 g/dL) - Hematocrit: 37.4 (35-45%) Plan: 1. Admit to the pediatric inpatient unit. 2. Vital signs every 4 hours. 3. Continuous pulse oximetry. 4. Height and weight on admission. 5. Regular diet for age. Encourage oral fluids. 6. O2 2L/min per nasal cannula. 7. D5 ½ NS with 20 mEq KCl/L at 61 mL/hr. Saline lock IV when patient is able to meet maintenance fluid requirements via oral intake. 8. Medications: - Cefuroxime 475 mg IV every eight hours (75-150 mg/kg every 8 hours) - Azithromycin elixir 190 mg orally x 1, to be followed by 95 mg once per day x 4 days (10 mg/kg x 1 dose then 5 mg/kg once per day for 4 more days) - Acetaminophen elixir 240 mg PO every 4-6 hours as needed for fever > 101.5F (38.6C) (10-15 mg/kg/dose) - Albuterol nebulized 0.5 mL in 2 mL NS Q 4 hours (first dose given in ER 2 hours ago) 9. Call provider for: - HR < 80, > 140 - RR < 18, > 34 - BP sys < 88, > 120; dias < 46, > 76 - Sats < 94 %", "type" : "Physician Notes" }, { "id" : "sabina-vasquez-mar-history-7", "summary" : "9/25/2026 12:02 Nancy Wright, Registered Nurse Yes", "type" : "Medication administration history — albuterol sulfate" }, { "id" : "sabina-vasquez-mar-history-8", "summary" : "9/25/2026 12:02 Nancy Wright, Registered Nurse Yes", "type" : "Medication administration history — D5 1/2 NS + 20 mEq KCl" }, { "id" : "sabina-vasquez-section-current-care-providers", "summary" : "Martha Harris | Admitting Physician\nNancy Wright | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "sabina-vasquez-clarification-10", "summary" : "Source scenario discrepancy: chief complaint denies fever and emphasizes asthma exacerbation; physician narrative describes fever, right lower lobe pneumonia/effusion and antibiotic treatment. Azithromycin remains Pending; cefuroxime is narrative-only and has not been invented as an active order. Source allergy table is empty, but physician history explicitly states no known allergies.", "type" : "Chart clarification" }, { "id" : "sabina-vasquez-clarification-11", "summary" : "Structured albuterol frequency is continuous, but directions offer q20min ×3 or short-term continuous plus ipratropium. Continuous mg/hr rate is absent. Clarify intended regimen; do not interpret 2.85 mg as a continuous hourly rate.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Martha Harris, Admitting Physician", "category" : "Dietary", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-1", "orderText" : "Cardiac Monitor & Pulse Oximetry; cont.; Stat; Source due: 9/25/2026 12:02", "status" : "Active" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Nursing", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-2", "orderText" : "Admission to floor, pediatric; x1 (1 time only), 1 time only; Routine; Admit to pediatric inpatient unit.", "status" : "Pending" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Nursing", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-3", "orderText" : "SBAR communication; cont.; Routine; Call provider if: HR < 80, > 140; RR < 18, > 34; BP sys < 88, > 120; dias < 46, > 76; SpO2 < 94%", "status" : "Pending" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-4", "orderText" : "Oxygen; cont.; Stat; Humidified O2 via nasal cannula titrate to maintain SpO2 ≥94% Source due: 9/25/2026 12:02", "status" : "Active" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-5", "orderText" : "Pulmonary Index Score (PIS); x1 (1 time only), 1 time only; Routine; Document on arrival and q20–30 min during treatment Source due: 9/25/2026 12:02", "status" : "Active" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-6", "orderText" : "Intake and output assessment, pediatric; cont.; Routine; Encourage oral fluid intake.", "status" : "Pending" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-7", "orderText" : "Pulse oximetry, pediatric; cont.; Routine; Continuous pulse oximetry monitoring.", "status" : "Pending" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-8", "orderText" : "Vital Signs; q15min (Every 15 minutes), Every 15 minutes; Stat; Source due: 9/25/2026 12:02", "status" : "Active" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Nursing: Procedure", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-9", "orderText" : "Intermittent infusion device flushing, pediatric; x1 (1 time only), 1 time only; Routine; Saline lock IV when patient is able to meet maintenance fluid requirements via oral intake.", "status" : "Pending" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-10", "orderText" : "dexamethasone (oral); 11.4 mg Oral (PO); x1 (1 time only), 1 time only; Scheduled, Stat; Source due: 9/25/2026 12:02", "status" : "Active" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-11", "orderText" : "azithromycin; 190 mg Oral (PO); x1 (1 time only), 1 time only; Scheduled; Azithromycin 190 mg (10 mg/kg) orally today X 1 day, followed by 95 mg (5 mg/kg) orally once per day x 4 days.", "status" : "Pending" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-12", "orderText" : "magnesium sulfate (injection); 950 mg Intravenous (IV); x1 (1 time only), 1 time only; Scheduled; over 20 minutes if no improvement after 3 albuterol/ipratropium doses and glucocorticoids Source due: 9/25/2026 12:02", "status" : "Active" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:12:00", "id" : "sabina-vasquez-order-13", "orderText" : "albuterol sulfate; 2.85 mg Inhalation; cont.; Scheduled, Stat; Albuterol nebulized + ipratropium bromide 250 mcg q20min ×3 (or short-term continuous for first hour) Source due: cont. Structured albuterol frequency is continuous, but directions offer q20min ×3 or short-term continuous plus ipratropium. Continuous mg/hr rate is absent. Clarify intended regimen; do not interpret 2.85 mg as a continuous hourly rate.", "status" : "Held — clarification required" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-14", "orderText" : "acetaminophen; 240 mg Oral (PO); PRN; Acetaminophen 240 mg (10-15 mg/kg/dose) PO every 4-6 hours as needed for fever > 38.6 C (101.5 F). Source due: PRN", "status" : "Active" }, { "author" : "Martha Harris, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T12:02:00", "id" : "sabina-vasquez-order-15", "orderText" : "D5 1/2 NS + 20 mEq KCl; 61 ml per hr Intravenous (IV); cont.; Cont. Infusion; Source due: cont. Potassium concentration is 20 mEq/L per physician narrative.", "status" : "Active" } ], "overview" : { "height" : "47 in / 119.4 cm", "isolationIndicator" : "Standard", "religion" : "Catholic", "weightKg" : 19.1 }, "vitals" : [ { "bloodPressure" : "98/60", "dateTime" : "2026-09-25T12:02:00", "heartRate" : 128, "id" : "sabina-vasquez-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 36, "spo2" : "93", "temperature" : "98.9 °F (37 °C), 37 °C Temporal" } ] }, "patient" : { "admitDateTime" : "2026-09-25T12:02:00", "admittingDiagnosis" : "Asthma, pediatric", "allergies" : [ ], "attending" : "Martha Harris, Admitting Physician", "chartDisplayName" : "Vasquez, Sabina", "codeStatus" : "Full Code", "dob" : "3/3/XX", "history" : { "chiefComplaint" : "5-year-old female (height 47 inches, weight 42 lbs) with known asthma presents to the ED with a 1-day history of wheezing, cough, and increased work of breathing. Symptoms began yesterday morning after a recent upper respiratory infection (runny nose and cough for 3 days). Mother reports progressive wheezing, shortness of breath, and use of belly muscles to breathe. Sabina has been less active and is breathing faster than usual. No fever, no vomiting, no diarrhea, no rash. Mother states Sabina has a history of asthma diagnosed at age 3 and is prescribed a daily low-dose inhaled corticosteroid controller, but they ran out 2 days ago and have not refilled it yet. Mother administered albuterol MDI (2 puffs) twice at home with only partial and temporary relief. No recent ER visits or hospitalizations for asthma. No known triggers today other than the cold. No sick contacts at home. Patient is otherwise healthy with no other medical problems. Immunizations up to date per mother. No allergies. No medications at home currently.", "pastMedicalHistory" : [ "General Medical History / Disease/Condition / : Asthma, pediatric", "General Medical History / Active: Active", "General Medical History / Disease/Condition / : Otitis media, pediatric", "General Medical History / Resolved: Resolved", "General Medical History / Notes: Diagnosed with asthma at age 3 in Mexico. Multiple ear infections as an infant and toddler.", "Transfusion History / Previous Blood Transfusion?: No", "Pain History / History of Chronic Pain?: No" ], "pastSurgicalHistory" : [ "Previous Surgical Procedures: No prior surgical history" ], "socialHistory" : [ "Age: 5 years", "Home Situation / Relationship / Relationship: Father", "Home Situation / Name / Name: David Vasquez", "Home Situation / Primary Residence?: Primary Residence?", "Home Situation / Relationship / Relationship: Mother", "Home Situation / Name / Name: Maria Vasquez", "Home Situation / Primary Residence?: Primary Residence?", "Home Situation / Name / Name: Michael", "Home Situation / Sex / Sex: M", "Home Situation / Age / Age: 4", "Home Situation / Name / Name: John", "Home Situation / Sex / Sex: M", "Home Situation / Age / Age: 2", "Education / Enrolled in School?: No", "Environmental Home Assessment Help - What Environmental Home Assessment means / Type of Dwelling: Own house", "Environmental Home Assessment Help - What Environmental Home Assessment means / Age of Home: Post-1978", "Environmental Home Assessment Help - What Environmental Home Assessment means / Type of Heat: Electric", "Environmental Home Assessment Help - What Environmental Home Assessment means / Lead Paint: Not tested/Don’t know", "Environmental Home Assessment Help - What Environmental Home Assessment means / Radon: Not tested/Don’t know", "Environmental Home Assessment Help - What Environmental Home Assessment means / Drinking Water Source: Public water system", "Nicotine Use / Is patient exposed to second-hand smoke?: No", "Alcohol Use / Any Alcohol Use in the Home?: No", "Drug Use / Any Drug Use in the Home?: No", "Violence Screening / Any History of Violence in the Home?: No", "Violence Screening / Does Patient Feel Safe at Home?: Yes", "Violence Screening / Does Patient Feel Safe in Current Environment (Work, School, etc.)?: Yes", "Violence Screening / Has Anyone Ever Hurt Patient Emotionally, Physically, or Sexually?: No", "Nutritional Screening / Type of Milk Given: 2% Milk", "Nutritional Screening / Amount: 24", "Nutritional Screening / Recent Weight Lost Without Trying?: No", "Nutritional Screening / Decreased Appetite?: No", "Nutritional Screening / Does patient have diabetes?: No", "Nutritional Screening / Stool Frequency: Every other day", "Nutritional Screening / Stool Description: Formed", "Nutritional Screening / Last Bowel Movement Days: 1", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment", "Exercise Screening / Exercise Frequency: Daily", "Exercise Screening / Duration of Exercise: 60 mins", "Exercise Screening / Intensity: Moderate", "Exercise Screening / Type(s): Plays in backyard with siblings", "Exercise Screening / Was Patient Counseled on Exercise?: Yes", "Other Safety Measures / Seatbelt/Carseat Use?: Always", "Other Safety Measures / Bicycle/ATV/Motorcycle Helmet Use?: Always", "Other Safety Measures / Sun Protection?: Always", "Other Safety Measures / Working Smoke Detectors in the Home?: Yes", "Other Safety Measures / Working Carbon Monoxide Detectors in the Home?: Yes", "Other Safety Measures / Working Fire Extinguisher in the Home?: Yes" ] }, "mrn" : "PCS25003", "sex" : "Female", "simulatedFullName" : "Sabina Vasquez", "unit" : "RCC Children's Medical Center" }, "setting" : "RCC Children's Medical Center", "snapshots" : [ { "activityIds" : [ ], "id" : "sabina-vasquez-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2026-09-25T12:02:00", "sourcePath" : "DocuCare instructor chart: Sabina Vasquez", "title" : "Captured chart" } ], "subtitle" : "N22 practice record", "tags" : [ "N22", "DocuCare migration" ], "title" : "Sabina Vasquez" }, "packageId" : "docucare-n22-sabina-vasquez-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated educational record only. Not for clinical care. Review the chart and faculty directions before practice." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "n22-sabina-vasquez", "instructions" : "Open the assigned patient chart. Confirm name, DOB and MRN; review allergies, notes, vitals, labs, orders and the MAR. Discuss missing or conflicting information with faculty. Held and discontinued medications are for review and are not active administration tasks. Scenario dates are historical. Follow your faculty directions.", "title" : "Sabina Vasquez" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:51.428231+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n22-eva-madison", "learningLevel" : "N22", "panels" : { "assessments" : [ { "author" : "Nathan Winters, Registered Nurse", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-assessment-1", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: abdomen\nOnset Days: 2\nOnset Hours: 0\nOnset Minutes: 0\nOnset Relative To Timing Based On: before admission\nPain Frequency: Constant\nType Of Pain: Acute\nPain Goal: 0 - No Pain\nAggravating Factors: Breathing\nAggravating Factors: Eating\nPain Rating: 7\nPain Characteristics: Aching" } ], "labs" : [ { "category" : "Other", "collectedDateTime" : "2021-10-09T23:45:00", "flag" : "High", "id" : "eva-madison-lab-1", "referenceRange" : "70-100", "result" : "999", "test" : "Glucose" } ], "medications" : [ { "doseRouteFrequency" : "4mg Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "ondansetron", "id" : "eva-madison-med-11", "nextDue" : "2021-10-09T23:45:00", "notes" : "Source due: 10/9/2021 23:45", "orderedBy" : "Marilyn Romera, Primary Care Physician", "orderedDateTime" : "2021-10-09T23:45:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "500 ML Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "0.9% NaCl Bolus", "id" : "eva-madison-med-12", "nextDue" : "2021-10-09T23:45:00", "notes" : "over 1 hour (first bolus) Source due: 10/9/2021 23:45", "orderedBy" : "Marilyn Romera, Primary Care Physician", "orderedDateTime" : "2021-10-09T23:45:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "100 ml per hr Intravenous (IV) cont.", "drug" : "D5 ½NS + 40 mEq KCl/L", "id" : "eva-madison-med-13", "nextDue" : "2021-10-09T23:45:00", "notes" : "After bolus Add potassium only after initial bolus and serum K+ confirmed <5.5 mEq/L Adjust rate per serial labs to correct dehydration without rapid osmolality drop Source due: 10/9/2021 23:45 Source physician plan says 1.5× maintenance while order says 100 mL/hr; verify intended rate and potassium prerequisites. No missing potassium results invented.", "orderedBy" : "Marilyn Romera, Primary Care Physician", "orderedDateTime" : "2021-10-09T23:45:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "5 units/hr Intravenous (IV), after initial fluid bolus; verify concentration", "drug" : "Regular Insulin", "id" : "eva-madison-med-14", "notes" : "No insulin bolus Goal glucose decrease 50 mg/dL/hr Source due: 10/9/2021 23:45 Do not administer from this unresolved source order. Insulin concentration and corresponding pump rate are missing. Physician plan specifies 5 units/hr after bolus with no insulin bolus; pharmacy preparation must be clarified before administration.", "orderedBy" : "Marilyn Romera, Primary Care Physician", "orderedDateTime" : "2021-10-09T23:45:00", "section" : "Scheduled", "status" : "Held — clarification required" } ], "notes" : [ { "id" : "eva-madison-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "id" : "eva-madison-provider-review-of-systems", "summary" : "Constitutional (e.g., fever, weight loss) / Notes: Positive for fatigue, unintentional weight loss of 8 lbs over 3 weeks, and polydipsia. Negative for fever, chills, night sweats.\nHEENT / Notes: Eyes: Positive for occasional blurred vision. Negative for pain, redness, discharge, or double vision. Ears, Nose, Throat: Negative for hearing loss, tinnitus, ear pain, nasal congestion, sinus pain, sore throat, or hoarseness.\nCardiovascular / Notes: Positive for tachycardia. Negative for chest pain, palpitations, orthopnea, or edema.\nRespiratory / Notes: Positive for nausea, vomiting (6–8 episodes today, non-bloody/non-bilious), and diffuse crampy abdominal pain (6/10). Negative for diarrhea, constipation, hematemesis, melena, or dysphagia.\nGastrointestinal / Notes: Positive for nausea, vomiting (6–8 episodes today, non-bloody/non-bilious), and diffuse crampy abdominal pain (6/10). Negative for diarrhea, constipation, hematemesis, melena, or dysphagia.\nGenitourinary / Notes: Positive for polyuria (frequent urination every 1–2 hours daytime and 4–5 times nightly) and dark yellow urine. Negative for dysuria, hematuria, or flank pain.\nMusculoskeletal / Notes: Negative for joint pain, swelling, stiffness, or muscle weakness.\nIntegumentary (skin and/or breast) / Notes: Negative for rash, lesions, or pruritus. Skin dry with poor turgor noted on exam.\nNeurological / Notes: Positive for mild lethargy/fatigue. Negative for headache, dizziness (except when standing), seizures, numbness, tingling, or focal weakness.\nPsychiatric / Notes: Positive for irritability secondary to discomfort. Negative for depression, anxiety, suicidal ideation, or hallucinations.\nEndocrine / Notes: Positive for new-onset polyuria, polydipsia, and weight loss suggestive of hyperglycemia. No known prior thyroid or adrenal issues.\nHematologic/Lymphatic / Notes: Negative for easy bruising, bleeding, or lymphadenopathy.\nAllergic/Immunologic / Notes: No known allergies or recurrent infections.", "type" : "Provider Review Of Systems" }, { "id" : "eva-madison-family-health-history", "summary" : "Family History: Denies knowledge of significant family history", "type" : "Family Health History" }, { "author" : "Marilyn Romera , Primary Care Physician", "dateTime" : "2021-10-10T00:00:00", "id" : "eva-madison-note-1", "summary" : "Chief Complaint: Vomiting and abdominal pain for 2 days (new-onset type 1 diabetes mellitus with moderate diabetic ketoacidosis). History of Present Illness: 14-year-old previously healthy female (height 5'4\", weight 110 lbs) brought in by ambulance with mother for 2 days of persistent vomiting and diffuse abdominal pain. Over the preceding 3 weeks she has had progressive polyuria, polydipsia, fatigue, and unintentional 8 lb weight loss. Symptoms escalated today with 6–8 episodes of non-bloody/non-bilious emesis and crampy abdominal pain rated 7/10. Oral intake minimal; last urine output small and dark yellow ~8 hours ago. Mother reports deep rapid breathing and fruity breath odor. No fever, diarrhea, or sick contacts. No prior diabetes diagnosis. Review of Systems: As per triage and bedside notes: positive for polyuria, polydipsia, weight loss, Kussmaul respirations, abdominal pain, nausea/vomiting, fatigue, and mild lethargy. All other systems negative. Physical Exam: General: Alert, oriented ×3 but mildly lethargic and fatigued; appears thin and dehydrated. Vital Signs: Temp 37.2°C, HR 132 (sinus tachycardia), BP 96/58 supine, RR 34 (Kussmaul), SpO2 97% on room air, POC glucose 999 mg/dL. HEENT: Dry mucous membranes, slightly sunken eyes, fruity breath odor. Neck: Supple, no thyromegaly. Lungs: Clear to auscultation, Kussmaul pattern noted. Cardiovascular: Tachycardic, regular rhythm, no murmurs; capillary refill 3 seconds. Abdomen: Soft, diffusely tender to palpation, hyperactive bowel sounds, no rebound/guarding. Skin: Warm, dry, poor turgor with tenting. Neuro: Alert and oriented ×3, follows commands, no focal deficits; mild lethargy. Extremities: No edema or cyanosis. Data: POC glucose 528 mg/dL VBG: pH 7.12, HCO₃ 9 mEq/L, anion gap 22 Beta-hydroxybutyrate 6.2 mmol/L CMP: Na 128 (corrected 140), K 5.4, BUN 26, Cr 1.1 HbA1c 12.8% (new diagnosis) Other labs pending Assessment: 14-year-old female with new-onset type 1 diabetes mellitus presenting in moderate diabetic ketoacidosis (hyperglycemia >200 mg/dL, venous pH <7.3, bicarb <18 mEq/L, ketosis with BOHB >3 mmol/L). Precipitated by delayed diagnosis (classic 3-week prodrome of polyuria/polydipsia/weight loss followed by vomiting/abdominal pain). Moderate dehydration and metabolic acidosis present. At risk for cerebral edema. Plan: Immediate Management – NS bolus 500 mL (10 mL/kg) over 1 hour, then D5 ½NS + 40 mEq KCl/L at 1.5× maintenance. Start regular insulin IV infusion at 5 units/hr (0.1 units/kg/hr) after bolus. Strict NPO, hourly glucose, q2h labs. Monitoring – Continuous cardiac monitor, q1h neuro checks for cerebral edema, strict I&O. Consults – STAT Pediatric Endocrinology and PICU admission. Symptom Control – Ondansetron 4 mg IV PRN nausea, acetaminophen PRN pain. Education – Begin diabetes teaching with mother (sick-day rules, insulin, BG monitoring) once stable. Social work support for new chronic illness. Disposition – Admit to PICU for DKA protocol and new T1DM education. Reassess in 1 hour.", "type" : "Physician Notes" }, { "author" : "Nathan Winters , Registered Nurse", "dateTime" : "2021-10-09T23:55:00", "id" : "eva-madison-note-2", "summary" : "Patient brought in by ambulance with mother and is alert and oriented ×3 with mild lethargy (LOC: drowsy but arousable to voice, follows commands appropriately). General appearance is that of a thin, fatigued adolescent in moderate distress with Kussmaul respirations and a noticeable fruity (acetone) breath odor. Pulse is tachycardic at 132 bpm and regular; patient is connected to cardiac monitor showing sinus tachycardia. Respirations are deep and rapid at 34 breaths per minute with Kussmaul pattern. Temperature is 37.2°C oral. Skin is warm, dry, and pale with poor turgor (tenting 3 seconds) and capillary refill of 3 seconds. No cyanosis or diaphoresis noted. Patient reports diffuse abdominal pain 7/10 and extreme thirst; mother at bedside providing support. All findings consistent with moderate DKA and dehydration; continuing frequent monitoring and awaiting provider orders for fluids and insulin.", "type" : "Nursing - Shift" }, { "author" : "Nathan Winters , Registered Nurse", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-note-3", "summary" : "14 y/o female with 3-week history of polyuria, polydipsia, fatigue, and 8 lb weight loss. Worsened over past 2 days with persistent vomiting (6–8 episodes today) and diffuse crampy abdominal pain. Minimal PO intake. Last urine output ~8 hours ago (small, dark yellow). Mother notes deep rapid breathing and fruity breath odor today. No fever, no diarrhea, no recent illness in family. Brought in by ambulance after mother called 911 due to increasing lethargy and inability to keep fluids down.", "type" : "Nursing - Admission" }, { "id" : "eva-madison-section-immunizations", "summary" : " Birth to Adult Immunizations: Td/Tdap, Varicella, HPV (female), Zoster, MMR 1, MMR 2, Rubella, Polio, Hepatitis A, Hepatitis B\n Titers: N/A\n10/9/2021 23:45 | Birth to Adult Immunizations: Td/Tdap, Varicella, HPV (female), Zoster, MMR 1, MMR 2, Rubella, Polio, Hepatitis A, Hepatitis B Titers: N/A", "type" : "Immunizations" }, { "id" : "eva-madison-section-current-care-providers", "summary" : "Marilyn Romera | Primary Care Physician\nNathan Winters | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "eva-madison-clarification-9", "summary" : "Insulin concentration and corresponding pump rate are missing. Physician plan specifies 5 units/hr after bolus with no insulin bolus; pharmacy preparation must be clarified before administration.", "type" : "Chart clarification" }, { "id" : "eva-madison-clarification-10", "summary" : "Source discrepancies: detailed physician/HPI describes newly diagnosed type 1 diabetes; library description says known diabetes. Detailed history retained. Physician note contains both glucose 999 and 528 mg/dL without clear separate times; laboratory row remains 999. Preschool grade/school fields conflict with age 14 and are retained as unverified source history. Respiratory ROS repeats GI content; actual respiratory findings remain in physician/nursing notes. Fluid plan and structured infusion rate require reconciliation.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Not specified", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-1", "orderText" : "Neuro Checks – q1h (level of consciousness, pupils, headache, vomiting) – hold for cerebral edema protocol if changes; cont.; Stat; Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Not specified", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-2", "orderText" : "Strict I&O – Hourly urine output, daily weights (bed scale); cont.; Stat; Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Not specified", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-3", "orderText" : "NPO – Strict nothing by mouth; cont.; Stat; Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Not specified", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-4", "orderText" : "Bedrest with bathroom privileges; x1 (1 time only), 1 time only; Stat; Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Not specified", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-5", "orderText" : "Consult: Pediatric Endocrinology; x1 (1 time only), 1 time only; Stat; Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Not specified", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-6", "orderText" : "Admit to PICU; x1 (1 time only), 1 time only; Stat; Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Nursing", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-7", "orderText" : "IV Access – Insert two large-bore peripheral IVs (or one if difficult); x1 (1 time only), 1 time only; Stat; Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Nursing", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-8", "orderText" : "Labs – STAT CMP, venous blood gas, beta-hydroxybutyrate, CBC, HbA1c, magnesium, phosphorus, serum ketones; x1 (1 time only), 1 time only; Stat; Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Nursing: Monitoring", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-9", "orderText" : "POC Glucose – STAT and q1h; x1 (1 time only), 1 time only; Stat; Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Nursing: Monitoring", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-10", "orderText" : "Cardiac Monitor – Continuous telemetry; cont.; Stat; Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Pharmacy", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-11", "orderText" : "ondansetron; 4mg Intravenous (IV); x1 (1 time only), 1 time only; Scheduled, Stat; Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Pharmacy", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-12", "orderText" : "0.9% NaCl Bolus; 500 ML Intravenous (IV); x1 (1 time only), 1 time only; Scheduled, Stat; over 1 hour (first bolus) Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Pharmacy", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-13", "orderText" : "D5 ½NS + 40 mEq KCl/L; 100 ml per hr Intravenous (IV); cont.; Cont. Infusion; After bolus Add potassium only after initial bolus and serum K+ confirmed <5.5 mEq/L Adjust rate per serial labs to correct dehydration without rapid osmolality drop Source due: 10/9/2021 23:45", "status" : "Active" }, { "author" : "Marilyn Romera, Primary Care Physician", "category" : "Pharmacy", "dateTime" : "2021-10-09T23:45:00", "id" : "eva-madison-order-14", "orderText" : "Regular Insulin; 5 ml per hr Intravenous (IV); cont.; Cont. Infusion, Stat; No insulin bolus Goal glucose decrease 50 mg/dL/hr Source due: 10/9/2021 23:45 Insulin concentration and corresponding pump rate are missing. Physician plan specifies 5 units/hr after bolus with no insulin bolus; pharmacy preparation must be clarified before administration.", "status" : "Held — clarification required" } ], "overview" : { "height" : "64 in / 162.6 cm", "isolationIndicator" : "Standard", "religion" : "Christian", "weightKg" : 49.9 }, "vitals" : [ { "bloodPressure" : "96/58", "dateTime" : "2021-10-10T00:00:00", "heartRate" : 132, "id" : "eva-madison-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 34, "spo2" : "97", "temperature" : "100 °F (38 °C), 38 °C Tympanic" } ] }, "patient" : { "admitDateTime" : "2021-10-09T23:45:00", "admittingDiagnosis" : "Diabetic ketoacidosis, pediatric", "allergies" : [ ], "attending" : "Marilyn Romera, Primary Care Physician", "chartDisplayName" : "Madison, Eva", "codeStatus" : "Full Code", "dob" : "1/28/XX", "history" : { "chiefComplaint" : "Patient is a 14-year-old previously healthy female who presents with a 2-day history of persistent vomiting and diffuse abdominal pain. Symptoms began gradually 3 weeks ago with increased thirst (polydipsia – drinking 2–3 liters of water daily) and frequent urination (polyuria – waking 4–5 times nightly to urinate, daytime voids every 1–2 hours). Over the past 3 weeks she has experienced progressive fatigue, decreased appetite, and unintentional weight loss. Two days ago she developed nausea followed by non-bloody, non-bilious vomiting (6–8 episodes today, increasing in frequency) and crampy, diffuse abdominal pain (rated 6/10, constant, worse after attempting oral intake). No diarrhea, no hematemesis, no melena. No fever, no cough, no dysuria, no headache, no vision changes beyond occasional blurring. Mother reports decreased oral intake over the past 48 hours (only sips of water and Gatorade). Last urine output was small volume and dark yellow approximately 8 hours prior to arrival. No recent travel, no sick contacts, no new medications, no known ingestions. Family attended a barbecue 3 weeks ago but no one else ill. Patient denies sexual activity, drug/alcohol use, or intentional weight-loss behaviors. Menarche at age 12, last menstrual period 3 weeks ago (normal).", "pastMedicalHistory" : [ "General Medical History: Denies prior medical problems", "Transfusion History / Previous Blood Transfusion?: No", "Pain History / History of Chronic Pain?: No" ], "pastSurgicalHistory" : [ "Previous Surgical Procedures: No prior surgical history" ], "socialHistory" : [ "Age: 14 years", "Home Situation / Relationship / Relationship: Mother", "Home Situation / Name / Name: Joanna Madison", "Home Situation / Primary Residence?: Primary Residence?", "Home Situation / Relationship / Relationship: Father", "Home Situation / Name / Name: Eric Madison", "Home Situation / Primary Residence?: Primary Residence?", "Home Situation / Name / Name: Chance", "Home Situation / Sex / Sex: M", "Home Situation / Age / Age: 1", "Education / Enrolled in School?: Yes", "Education / Grade: Pre-K", "Education / Name of School: Raintree Elementary", "Environmental Home Assessment Help - What Environmental Home Assessment means / Type of Dwelling: Own house", "Environmental Home Assessment Help - What Environmental Home Assessment means / Age of Home: Post-1978", "Environmental Home Assessment Help - What Environmental Home Assessment means / Type of Heat: Electric", "Environmental Home Assessment Help - What Environmental Home Assessment means / Lead Paint: Not tested/Don’t know", "Environmental Home Assessment Help - What Environmental Home Assessment means / Radon: Not tested/Don’t know", "Environmental Home Assessment Help - What Environmental Home Assessment means / Drinking Water Source: Public water system", "Nutritional Screening / Stool Frequency: 5-6/day", "Nutritional Screening / Stool Description: Loose", "Nutritional Screening / Stool Description: Watery", "Nutritional Screening / Stool Description: Foul-Smelling", "Nutritional Screening / Last Bowel Movement Days: 0", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment" ] }, "mrn" : "1378543", "sex" : "Female", "simulatedFullName" : "Eva Madison", "unit" : "RCC Children's Medical Center" }, "setting" : "RCC Children's Medical Center", "snapshots" : [ { "activityIds" : [ ], "id" : "eva-madison-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2021-10-10T00:00:00", "sourcePath" : "DocuCare instructor chart: Eva Madison", "title" : "Captured chart" } ], "subtitle" : "N22 practice record", "tags" : [ "N22", "DocuCare migration" ], "title" : "Eva Madison" }, "packageId" : "docucare-n22-eva-madison-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated educational record only. Not for clinical care. Review the chart and faculty directions before practice." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "n22-eva-madison", "instructions" : "Open the assigned patient chart. Confirm name, DOB and MRN; review allergies, notes, vitals, labs, orders and the MAR. Discuss missing or conflicting information with faculty. Held and discontinued medications are for review and are not active administration tasks. Scenario dates are historical. Follow your faculty directions.", "title" : "Eva Madison" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:51.428231+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n22-leo-chen", "learningLevel" : "N22", "panels" : { "assessments" : [ { "author" : "Jennifer Lopez, Registered Nurse", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-assessment-1", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: General\nOnset Days: 0\nOnset Hours: 0\nOnset Minutes: 0\nOnset Relative To Timing Based On: after admission\nPain Frequency: Constant\nType Of Pain: Acute\nPain Goal: 2\nAggravating Factors: Movement\nAggravating Factors: Coughing\nAggravating Factors: Breathing\nAlleviating Factors: Medication\nPain Scale Used: FLACC\nPain Rating: 10 - Unbearable Pain\nPain Characteristics: Aching\nPain Characteristics: Dull\nPain Characteristics: Burning" } ], "intakeOutput" : { "documentedIntakeTotalMl" : 0, "documentedNetMl" : -134, "documentedOutputTotalMl" : 134, "intakeEntries" : [ ], "outputEntries" : [ { "amountMl" : 18, "id" : "leo-chen-output-1", "time" : "2026-09-25T12:27:00", "type" : "Urine" }, { "amountMl" : 20, "id" : "leo-chen-output-2", "time" : "2026-09-25T13:12:00", "type" : "Urine" }, { "amountMl" : 22, "id" : "leo-chen-output-3", "time" : "2026-09-25T14:12:00", "type" : "Urine" }, { "amountMl" : 23, "id" : "leo-chen-output-4", "time" : "2026-09-25T15:12:00", "type" : "Urine" }, { "amountMl" : 25, "id" : "leo-chen-output-5", "time" : "2026-09-25T16:12:00", "type" : "Urine" }, { "amountMl" : 26, "id" : "leo-chen-output-6", "time" : "2026-09-25T17:12:00", "type" : "Urine" } ] }, "labs" : [ { "category" : "Other", "collectedDateTime" : "2026-09-25T11:12:00", "flag" : "Low", "id" : "leo-chen-lab-1", "result" : "7.26", "test" : "pH" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:12:00", "flag" : "Low", "id" : "leo-chen-lab-2", "result" : "34", "test" : "pCO2" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:12:00", "flag" : "Normal", "id" : "leo-chen-lab-3", "result" : "80", "test" : "paO2" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:12:00", "flag" : "Low", "id" : "leo-chen-lab-4", "result" : "16", "test" : "HCO3" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:12:00", "flag" : "Unverified", "id" : "leo-chen-lab-5", "result" : "-10", "test" : "BE" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "High", "id" : "leo-chen-lab-6", "referenceRange" : "4.0-9.0", "result" : "19.8", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "High", "id" : "leo-chen-lab-7", "referenceRange" : "3.90-4.98", "result" : "5.1", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "Normal", "id" : "leo-chen-lab-8", "referenceRange" : "12.0-15.5", "result" : "15.2", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "High", "id" : "leo-chen-lab-9", "referenceRange" : "35-45", "result" : "46", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "High", "id" : "leo-chen-lab-10", "referenceRange" : "140-400", "result" : "428", "test" : "Platelet Count (1000/mm3)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "Low", "id" : "leo-chen-lab-11", "referenceRange" : "135-145", "result" : "132", "test" : "Sodium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "Normal", "id" : "leo-chen-lab-12", "referenceRange" : "3.5-5.1", "result" : "5.1", "test" : "Potassium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "Normal", "id" : "leo-chen-lab-13", "referenceRange" : "98-107", "result" : "98", "test" : "Chloride (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "Low", "id" : "leo-chen-lab-14", "referenceRange" : "22-29", "result" : "18", "test" : "CO2 (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "High", "id" : "leo-chen-lab-15", "referenceRange" : "70-99", "result" : "192", "test" : "Glucose (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "High", "id" : "leo-chen-lab-16", "referenceRange" : "6-20", "result" : "28", "test" : "Blood Urea Nitrogen (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "Normal", "id" : "leo-chen-lab-17", "referenceRange" : "0.50-1.00", "result" : "0.7", "test" : "Creatinine (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "Low", "id" : "leo-chen-lab-18", "referenceRange" : "3.5 - 5.0", "result" : "2.8", "test" : "Albumin" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:27:00", "flag" : "High", "id" : "leo-chen-lab-19", "referenceRange" : "< 2", "result" : "3.8 mmol/L", "test" : "Lactate" } ], "medications" : [ { "doseRouteFrequency" : "70 mL/hr IV, first 8-hour phase from burn time", "drug" : "Fluid resuscitation: Lactated Ringer's (warmed) per pediatric Parkland formula.", "id" : "leo-chen-med-37", "nextDue" : "2026-09-25T11:14:00", "notes" : "Warmed Source due: 9/25/2026 11:14 Sequential resuscitation phases, not simultaneous infusions. Confirm burn time, prior infused volume and maintenance needs; titration per source urine-output/hemodynamic instructions.", "orderedBy" : "Dr. Sarah Ramirez, Admitting Physician", "orderedDateTime" : "2026-09-25T11:14:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "35 mL/hr IV, subsequent 16-hour phase; not concurrent with first phase", "drug" : "Fluid resuscitation: Lactated Ringer's (warmed) per pediatric Parkland formula.", "id" : "leo-chen-med-38", "nextDue" : "2026-09-25T19:12:00", "notes" : "Warmed Source due: 9/25/2026 19:12 Sequential resuscitation phases, not simultaneous infusions. Confirm burn time, prior infused volume and maintenance needs; titration per source urine-output/hemodynamic instructions.", "orderedBy" : "Dr. Sarah Ramirez, Admitting Physician", "orderedDateTime" : "2026-09-25T11:14:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "0.5ml Intramuscular (IM) x1 (1 time only), 1 time only", "drug" : "Tetanus toxoid", "id" : "leo-chen-med-39", "notes" : "Immunizations UTD per mother, but administer per burn protocol Source due: 9/25/2026 11:14 Do not administer from this unresolved source order. Source says immunizations are up to date but orders tetanus toxoid without age-appropriate product or verified series dates; later narrative says already administered. Clarify before another dose. CDC wound guidance does not indicate another vaccine when primary series is complete and last dose was less than five years ago. Reference: https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html", "orderedBy" : "Dr. Sarah Ramirez, Admitting Physician", "orderedDateTime" : "2026-09-25T11:14:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "1mcg/kg Intravenous (IV) q15min (Every 15 minutes), Every 15 minutes", "drug" : "Fentanyl", "id" : "leo-chen-med-40", "notes" : "Reassess pain q15-30min using FLACC scale (goal ≤4) Source due: PRN", "orderedBy" : "Dr. Sarah Ramirez, Admitting Physician", "orderedDateTime" : "2026-09-25T11:14:00", "section" : "PRN", "status" : "Active" } ], "notes" : [ { "id" : "leo-chen-allergy", "summary" : "Kiwi | Food | Angioedema | | Maria Gonzalez | 9/25/2026 11:12", "type" : "Allergy documentation" }, { "id" : "leo-chen-provider-review-of-systems", "summary" : "Constitutional (e.g., fever, weight loss) / Notes: Positive for profound hypothermia (core temp 94.0°F rectal), lethargy, pallor, cool/mottled skin, and poor perfusion. Patient initially inconsolable screaming progressing to weak moaning and lethargy. No fever reported prior to injury. Weight 12 kg per maternal/EMS report.\nHEENT / Notes: Head: Normocephalic, atraumatic. No deformities, no burns to scalp/face/neck. Anterior fontanelle closed/flat. Eyes: PERRL 3 mm bilaterally. Conjunctiva pale. No erythema, discharge, or burns. Extraocular movements limited by lethargy. Ears: Bilateral canals clear, tympanic membranes intact. No burns or drainage. Nose: Patent nares, no flaring, no soot, no singed vibrissae, no burns. Mouth/Throat: Mucosa pink/moist, no soot, no erythema/edema, no oral burns. Weak cry, no hoarseness or stridor. Supple, no JVD, trachea midline. No burns, no tenderness, no lymphadenopathy.\nCardiovascular / Notes: Profoundly tachycardic (HR 160, thready). Distant heart sounds. Peripheral pulses thready proximally, absent distally (radial/pedal). Capillary refill >4 seconds. BP 70/40 mmHg (profound hypotension). Flat neck veins. No murmurs.\nRespiratory / Notes: Tachypneic (RR 40, shallow/irregular). Symmetric chest rise, clear breath sounds bilaterally, no wheezes/crackles/retractions. SpO2 90% on 100% NRB. No stridor, no soot, no singed nasal hairs. No evidence of inhalation injury.\nGastrointestinal / Notes: Genital/perineal area with mixed partial- and full-thickness scald burns (~1% TBSA). Foley catheter placed without difficulty, initial clear yellow urine. No bleeding or gross abnormality otherwise.\nGenitourinary / Notes: Genital/perineal area with mixed partial- and full-thickness scald burns (~1% TBSA). Foley catheter placed without difficulty, initial clear yellow urine. No bleeding or gross abnormality otherwise.\nMusculoskeletal / Notes: Moves all extremities weakly to painful stimuli. No deformities, fractures, or joint effusions noted. No back/flank tenderness on log-roll. Posterior surfaces spared.\nIntegumentary (skin and/or breast) / Notes: Positive for extensive scald burns, estimated 31% TBSA mixed partial- and full-thickness: Anterior torso (chest to lower abdomen): ~12% (red, moist, blistered areas with central white/waxy leathery zones) Left arm: 9% circumferential (mixed depth, full-thickness centrally) Bilateral anterior/medial thighs: ~9% total (4.5% each, mixed depth) Perineum/genitals: ~1% Irregular splash pattern with drip marks, consistent with reported mechanism of pulling pot of hot water onto self. No glove/stock pattern, no spared creases, no immersion lines. Partial-thickness areas extremely tender; full-thickness areas insensate. Some intact blisters, minimal serous drainage. No other abrasions, ecchymoses, or suspicious injuries identified on full exposure/log-roll.\nNeurological / Notes: GCS 12 (E3 V4 M5): opens eyes to voice/pain, confused verbal (crying/moaning), localizes pain. Lethargic, disoriented, follows commands inconsistently. No focal deficits. Pupils equal/reactive.\nPsychiatric / Notes: Altered mental status secondary to pain, shock, and hypothermia. Severe distress with weak crying/moaning. No self-harm indicators.\nEndocrine / Notes: Negative. Stress hyperglycemia noted on initial point-of-care glucose (180 mg/dL per EMS).\nHematologic/Lymphatic / Notes: Negative for obvious bleeding or lymphadenopathy.\nAllergic/Immunologic / Notes: No known allergies. Up-to-date immunizations per mother.\nAdditional Notes / Notes: Primary survey completed per pediatric trauma protocol. Patient arrived via EMS following scald burn injury ~20 minutes prior. Mother (Anna Chen) at bedside providing history. Patient initially inconsolable, now intermittently moaning and lethargic. Obvious extensive burns noted on full exposure.", "type" : "Provider Review Of Systems" }, { "id" : "leo-chen-family-health-history", "summary" : "Notes: General: Non-contributory. No known hereditary or chronic medical conditions in immediate family. Parents: Mother (Anna Mei Chen, age 32): Healthy, no chronic illnesses, no history of burns or trauma-related conditions. Father (Kevin Jian Chen, age 34): Healthy, no chronic illnesses. Both parents deny any significant past medical history. Siblings: None (Leo is only child). Extended Family: Per mother, no known history of genetic disorders, congenital anomalies, bleeding/coagulation disorders, malignant hyperthermia, sudden cardiac death, seizures, asthma, diabetes, hypertension, or cancer in first-degree relatives (grandparents, aunts/uncles). No family history of child abuse or neglect reported. Other: No known family history of adverse reactions to anesthesia or relevant environmental exposures. Immunization status up-to-date in patient per maternal report; family follows routine pediatric care.", "type" : "Family Health History" }, { "author" : "Megan Walsh , Dietary/Nutrition", "dateTime" : "2026-09-26T13:12:00", "id" : "leo-chen-note-1", "summary" : "Reason for Consult: Evaluation of nutritional needs in 2-year-old with major burns (31% TBSA); initiate early enteral nutrition to support hypermetabolic state and wound healing. History/Background: Leo Chen, 2-year-old male (DOB 02/10/2024, weight 12 kg on admission, estimated height 87.6 cm), admitted yesterday with severe scald burns (31% TBSA mixed partial/full thickness) from hot water pull-down incident. Complicated by initial burn shock and hypothermia - now resolved with good response to Parkland resuscitation and warming. Currently NPO with NG tube in place (minimal output). No prior feeding issues; pre-injury diet per parents: Typical toddler diet (whole milk, table foods, snacks) with good appetite and growth. No allergies, intolerances, or GI history. Immunizations UTD. Parents at bedside providing history. Overnight course (per chart/nursing): Stable hemodynamics, UOP meeting goal (1-2 mL/kg/hr), core temp normal, pain controlled on fentanyl infusion. Transitioned to second phase Parkland fluids. No vomiting or high NG output. Ready for enteral nutrition initiation per PICU/Burn teams. Subjective: Parents report Leo was \"eating everything\" pre-injury (favorites: pasta, fruits, yogurt). No chewing/swallowing concerns. Express worry about \"how he'll eat with the tubes\" and long-term feeding. Objective: Anthropometrics: Weight 12 kg (50th percentile for age), estimated height 87.6 cm (50th percentile). Pre-injury weight assumed stable. Labs Reviewed (recent): Glucose 140 mg/dL (stress hyperglycemia, improving), prealbumin not yet drawn, electrolytes stable, mild CK elevation. Energy/Nutritional Needs Calculation (Pediatric Burn-Specific): Basal Metabolic Rate (estimated via Schofield equation for age/sex): ~650-700 kcal/day. Burn Hypermetabolism Adjustment: For >20% TBSA burns in children, requirements often 1.5-2x maintenance + burn factor. Estimated Total Energy: 1,800-2,200 kcal/day (150-180 kcal/kg/day initially, tapering as healing progresses). Protein: 2.5-3.5 g/kg/day (30-42 g/day) for wound healing and positive nitrogen balance. Fluid: Ongoing per Parkland; enteral to supplement as tolerated. Access: NG tube patent and confirmed placement. Current Intake: IVF only (Parkland LR + maintenance); no enteral yet. Assessment: 2-year-old with major burns (31% TBSA) in hypermetabolic phase requiring aggressive nutritional support to promote wound healing, preserve lean body mass, and prevent catabolism. High risk for malnutrition due to increased demands (up to 2x normal), NPO status, and stress response. Strengths: Young age with growth potential, supportive family, intact GI tract. Tolerating NG tube well overnight - appropriate for early enteral feeding. Goal: Meet 100% estimated needs via enteral route within 48-72 hours to preserve gut integrity and reduce infection risk. Plan/Recommendations: Route/Formula: Initiate continuous enteral tube feeds via NG tube. Formula: Age-appropriate polymeric high-protein formula (e.g., Pediasure Peptide 1.5 or similar high-calorie/peptide-based for tolerance in burns/stress). Goal: 1.5-1.8 kcal/mL with added protein modules if needed. Start trophic rate: 10 mL/hr x 4-6 hours, then advance by 10-20 mL/hr q4-6h as tolerated (monitor residuals q4h, goal <50% hourly rate). Target full rate: ~50-60 mL/hr continuous (providing ~1,800-2,000 kcal/day and 30-40g protein/day). Additives/Monitoring: Add protein modular (e.g., Beneprotein) if urine urea nitrogen indicates need. Monitor feeding tolerance: Gastric residuals q4h, abdominal exam, stools. Hold/advance per PICU protocol. Labs: Daily weights, weekly prealbumin/visceral proteins, monitor glucose (may need insulin if persistent hyperglycemia). Indirect calorimetry when stable for precise REE measurement. Long-Term: Transition to bolus feeds/oral as pain/edema resolve and grafting occurs. High-calorie oral supplements when PO advanced. Family education: Importance of nutrition for healing/scarring minimization; involve in feeding routines. Follow-Up: Daily nutrition rounds/visits; reassess needs q48h or with clinical changes. Coordinate with burn center team for continuity on transfer. Discussed plan with parents - reassured on gradual start and benefits (\"Good nutrition helps his skin heal faster and stronger\"). Parents agreeable. Thank you to PICU team for timely consult.", "type" : "Dietary/Nutrition Notes" }, { "author" : "Sophia Martinez , Child Life Specialist", "dateTime" : "2026-09-25T16:56:00", "id" : "leo-chen-note-2", "summary" : "Reason for Consult: Referred by PICU team for age-appropriate emotional support, pain/distress reduction, procedural preparation, and family coping assistance in a critically injured toddler with severe burns. History/Background: Leo Chen, 2-year-old male, admitted with 31% TBSA scald burns from accidental hot water incident at home. Witnessed by mother; prompt medical response. Child has been in significant pain/distress since injury, progressing from inconsolable screaming in ED to intermittent whimpering/lethargy in PICU. Receiving fentanyl infusion with good effect currently. Parents (Anna and Kevin Chen) highly distressed with expressed guilt (\"We should have been watching closer\"). No prior hospitalizations; Leo described as \"happy, active, curious toddler\" pre-incident. Family supportive but overwhelmed by critical care environment. Subjective (Observation and Family Report): Child: Limited verbal expression due to age and sedation/pain; communicates distress through crying, rigid posturing, and withdrawal from touch (except parental comfort). Responds positively to familiar voices (calms briefly when parents speak/sing). Parents: Tearful, anxious, expressing guilt and fear about Leo's pain and long-term outcome (\"Will he have scars forever?\"). Mother fatigued from constant bedside presence; father alternating shifts. Parents appreciative of updates but overwhelmed by monitors, tubes, and procedures. Objective (Direct Observation): Developmental Assessment: Typical 2-year-old milestones (mobile, curious, limited impulse control) - consistent with mechanism (reaching/pulling). Pre-injury: Enjoys books, music, bubbles, toy cars per parents. Current Coping/Response: FLACC scores improved (now 2-4/10 with infusion and parental presence), but spikes to 6-8/10 with position changes or vital signs checks. Child fixates on parents; separation anxiety evident when parents step away briefly. Environment: Room adapted with dim lighting, quiet music playing softly. Parents at bedside holding unburned hand/reading simple book. Interventions Provided Today: Introduced self with simple language/play demonstration. Provided sensory distraction: Bubbles (blow-by for infection control), soft music via tablet, lighted toy for visual tracking. Guided parents in comfort holds (skin-to-skin on unburned areas) and familiar routines (singing favorite song). Normalized environment: Explained monitors/tubes in simple terms (\"These helpers keep Leo safe and comfy\"). Used medical play kit to demonstrate IV on doll for parental understanding. Procedural support: Present during recent dressing check - used distraction (bubbles/story) to reduce crying. Assessment: Leo exhibiting age-appropriate fear, pain response, and separation anxiety in response to traumatic injury and hospitalization. High distress level improved with pharmacological and non-pharmacological interventions. Parents experiencing acute stress/guilt response common in accidental pediatric injuries; strong bonding and motivation to support child. Family strengths: Attentive, engaged, open to guidance. Risks: Potential for developmental regression, prolonged anxiety, and parental burnout during extended recovery. Plan: Child-Focused Interventions: Daily bedside play sessions tailored to tolerance (sensory toys, music, bubbles, simple books - all sanitized). Distraction/support during procedures (wound care, labs, VS) - coordinate with nursing. Monitor for signs of trauma response (regression, sleep disturbance); introduce coping tools (deep breathing via bubbles for parents to model). Family-Focused Interventions: Teach parents distraction/comfort techniques (e.g., guided imagery, favorite songs/stories). Encourage self-care (breaks, meals). Provide honest, simple explanations of procedures/recovery to reduce fear (\"Leo's skin is hurt and needs special bandages to heal strong\"). Prepare for upcoming wound care/debridement with medical play and visual aids. Long-Term Support: Facilitate sibling/extended family visits if appropriate post-transfer. Coordinate with burn center Child Life team for continuity. Offer legacy-building activities (handprints on unburned areas when stable). Follow-Up: Daily visits while inpatient; reassess coping q shift. Collaborate with Social Work for ongoing emotional resources and burn support groups. Thank you to nursing and medical teams for inclusive care. Parents verbalized feeling \"a little less scared\" after play session - Leo calmed quickly with bubbles. Will return this evening for bedtime routine support.", "type" : "Consult Notes" }, { "author" : "Laura Jenkins , Social Services", "dateTime" : "2026-09-25T15:27:00", "id" : "leo-chen-note-3", "summary" : "Reason for Consult: Mandatory consultation for all pediatric burn injuries to assess for possible non-accidental trauma; provide emotional support and resources to family. History/Sources of Information: Chart review: 2-year-old male with 31% TBSA scald burns from reported accidental pull-down of boiling water pot. Mechanism witnessed by mother. Prompt care-seeking. Direct interview: Separate conversations with mother (Anna Mei Chen) and father (Kevin Jian Chen) at bedside, with Child Life support. Parents cooperative, tearful, and consistent in history. Collateral: Discussion with ED/PICU teams and Burn Surgery (Dr. Hayes) - burn pattern described as consistent with accidental splash. Subjective: Parents report living in a small apartment (3650 Iowa Ave, Apt 204, Riverside, CA 92507) with Leo as their only child. Both parents work part-time; mother was home preparing lunch when incident occurred (\"I turned my back for just a second to grab pasta from the cabinet—he's so quick and curious now\"). Father arrived at hospital shortly after ED admission. Parents express profound guilt, shock, and fear (\"We had no idea he could reach that high\"). No history of prior CPS involvement, domestic violence, substance use, or mental health crises reported. Strong support network (extended family nearby). Parents attentive during interview - holding child (unburned areas), providing comfort, asking appropriate questions about care/recovery. No inconsistencies in storytelling between parents or compared to medical findings. Objective: Family Dynamics: Parents appropriately distressed, affectionate with child, and engaged with medical team. Leo responsive to parents' voices/touch (calms when held). Burn Pattern (per medical documentation/review): Irregular splash with variable depth; no immersion lines, glove/stocking pattern, or spared areas concerning for forced immersion. Distribution (torso, left arm circumferential, thighs, perineum) consistent with pull-down mechanism in a mobile toddler. No additional injuries (bruises, fractures, old scars). Risk Factors Assessed: Developmental stage appropriate (curious toddler reaching); kitchen hazard common in scalds. No red flags for neglect/abuse (prompt 911 call, immediate clothing removal). Supports: Parents have reliable transportation, insurance, and family nearby for assistance. Assessment: Low immediate concern for non-accidental trauma. History, burn pattern, parental presentation, and prompt care-seeking all highly consistent with accidental injury in a typical toddler household. Standard protocol requires reporting to CPS due to severity; initial report filed with reassuring details. Family experiencing acute trauma/grief response with guilt - at risk for prolonged emotional distress. Strengths: Supportive, cooperative parents with good insight. Plan: Child Protection: Mandatory CPS report filed (case opened for monitoring per protocol). No immediate safety concerns; child to remain hospitalized. Will follow up with CPS investigator if assigned. Reassured parents this is routine for serious pediatric burns and findings are supportive of accident. Emotional Support: Provided crisis counseling at bedside; normalized guilt feelings common in accidental injuries. Encouraged parental presence and involvement in care (e.g., comfort holds, reading to child). Coordinated with Child Life (Sophia Martinez) for ongoing age-appropriate support and procedural explanation. Resources: Offered burn family support group information and counseling referrals (hospital-based and community). Provided written materials on burn recovery emotional impacts and parent coping strategies. Discussed practical needs: Meal vouchers, lodging assistance if transfer to burn center occurs (parents plan to alternate stays). Home safety education: Emphasized stove guards, back burner use, pot handle turn-in, water heater temp ≤120°F, and constant supervision. Will reinforce with discharge planning. Follow-Up: Daily social work visits while inpatient. Coordinate with case management for burn center transfer support. Reassess family needs ongoing. Thank you to PICU and Burn teams for collaboration. Parents verbalized understanding and appreciation for support.", "type" : "Social Services Notes" }, { "author" : "Taylor Nguyen , Registered Nurse", "dateTime" : "2026-09-25T15:12:00", "id" : "leo-chen-note-4", "summary" : "Focused Assessment: Patient resting intermittently with eyes closed; arouses to voice. Parents at bedside providing comfort holds. Vital Signs: Core Temp 98.2°F, BP 100/60 mmHg, HR 128 bpm, RR 28/min, SpO2 98% on 4 L/min simple mask. FLACC 3/10 (grimacing with movement). Systems: CV: Strong peripheral pulses, cap refill 2 sec. Resp: Clear, easy effort. GI/GU: Abdomen soft; NG low suction with minimal output. UOP 22 mL/hr past 4 hours (goal met). Skin/Wounds: Dressings intact/dry; no increased edema or drainage noted on check. Extremities elevated. Neuro: GCS 15; more interactive with parents. Interventions/Response: Parkland LR @ ~70 mL/hr (first 8-hour phase); total infused ~800 mL. Fluids warmed. Fentanyl infusion @1 mcg/kg/hr; no bolus needed past hour (FLACC stable). Forced-air warmer continuing; room warm. Strict I&O accurate via Foley. Plan: Continue q15-30min VS initially, then q1h. Reassess pain q30min. Await Burn Surgery full eval. Family updated - tolerating well.", "type" : "Nursing - Progress Note" }, { "author" : "Dr. Robert Hayes , Consulting Physician", "dateTime" : "2026-09-25T13:52:00", "id" : "leo-chen-note-5", "summary" : "Reason for Consult: Evaluation and management of extensive scald burns in 2-year-old male with associated burn shock; rule out non-accidental trauma per protocol. History (from Chart Review and Family Discussion): Leo Chen is a 2-year-old previously healthy male who sustained scald burns ~1145 today after pulling a pot of boiling water off the stove. Incident witnessed by mother (Anna Chen), who immediately removed wet clothing and initiated cooling/care, calling 911 promptly. No delay in seeking care. ED/PICU course: Presented in burn shock (hypotension, tachycardia, hypothermia) with 31% TBSA burns. Aggressive resuscitation with warmed LR per Parkland, warming measures, and fentanyl. Stabilizing well (current VS improved, UOP responding, core temp normalizing). Parents at bedside throughout; cooperative and distressed. Social Work/CPS initial assessment reassuring. Objective: Vital Signs (current): Core Temp 98.0°F, BP 98/58 mmHg, HR 130 bpm, RR 28/min, SpO2 97% on 4 L/min simple mask. Weight 12 kg. General: Toddler male, calmer, resting with intermittent whimpering. Consolable by parents. Burn Exam (dressings removed at bedside for assessment; reapplied after): Total Body Surface Area (TBSA): Confirmed ~31% (pediatric Rule of Nines). Anterior torso (chest/abdomen, mixed depth): 12% Left arm (circumferential, mixed depth): 9% Bilateral thighs (anterior/medial splash, mixed depth): 9% (4.5% each) Perineum/genitals: 1% Depth: Mixed partial-thickness (2° - red, moist, blistered, painful) and full-thickness (3° - white/waxy/leathery areas, insensate in centers). Deeper areas noted on central torso, left arm (circumferential), and left thigh. Pattern: Irregular splash distribution with variable depth, drip marks, and irregular margins - highly consistent with reported mechanism of pulling hot liquid down onto self. No uniform depth, no glove/stockings pattern, no clear immersion lines, no spared areas suggestive of held immersion. No other traumatic injuries (bruising, fractures) noted on full exam. Edema: Moderate in burned areas; no tense compartments currently. Extremities elevated. Respiratory: No facial/neck burns; no stridor, hoarseness, soot, or singed hairs. Clear breath sounds. Low suspicion for inhalation injury but will monitor. Labs Reviewed: Initial lactate elevated but trending down; CK mildly elevated (expected). Assessment: 2-year-old male with major scald burns (31% TBSA, mixed 2°/3° depth) from hot water pull-down incident. Complicated by resolving burn shock and hypothermia - good response to resuscitation. Burn pattern and history highly consistent with accidental mechanism; no suspicious features for non-accidental trauma at this time (CPS aware and following). High risk for infection, fluid shifts, and long-term scarring/contractures. Requires specialized burn care. Plan: Wound Management: Initiate daily burn wound cleansing and topical antimicrobial therapy starting tomorrow AM (silver sulfadiazine 1% cream to open areas; non-adherent dressings). Maintain dry, clean dressings in interim; change q24h or PRN soiling. Biopsy not needed initially; depth will declare over next days. Surgical Planning: Anticipate need for early excisional debridement and autologous skin grafting for full-thickness areas (likely within 3-7 days, depending on stability). Circumferential left arm/thigh: Monitor closely for compartment syndrome (serial exams, elevate). Escharotomy if pulses deteriorate (unlikely with scald but possible). Fluid/Nutrition: Defer to PICU team (continue Parkland titration); strongly support early enteral nutrition (trophic feeds via NG tomorrow) to meet hypermetabolic demands. Pain/Support: Continue opioid regimen; involve Child Life for procedural prep. Infection Prophylaxis: No systemic antibiotics routinely; monitor for signs (fever, WBC trend). Tetanus covered. Rehabilitation: Early PT/OT consult for positioning, splinting, and ROM to prevent contractures (especially left arm and thighs). Disposition: Recommend transfer to Regional Pediatric Burn Center once hemodynamically stable (target tomorrow if trends continue). Will follow daily until transfer. Family: Discussed findings with parents - reassured on accidental pattern but explained prolonged recovery (multiple surgeries, scarring, therapy). Parents tearful but understanding; provided emotional support.", "type" : "Consult Notes" }, { "author" : "Dr. Emily Thompson , Primary Care Physician", "dateTime" : "2026-09-25T12:37:00", "id" : "leo-chen-note-6", "summary" : "Chief Complaint: 2-year-old male with severe scald burns complicated by burn shock and hypothermia, transferred from ED for ongoing resuscitation. History of Present Illness (HPI): Leo Chen is a previously healthy 2-year-old male who sustained extensive scald burns ~1145 today after pulling a pot of boiling water off the stove. Mechanism witnessed by mother (Anna Chen), who immediately removed wet clothing, wrapped in clean towel, and called 911. EMS arrived promptly; one IV established en route. ED course (arrival ~1200): Presented critically ill - inconsolable progressing to lethargic (GCS 12), profound hypotension (70/40), tachycardia (160), hypothermia (94.0°F core), tachypnea (40), SpO2 90% on NRB. Estimated 31% TBSA mixed partial/full thickness scald burns (anterior torso 12%, left arm circumferential 9%, bilateral thighs 9%, perineum 1%) with splash pattern consistent with reported accidental mechanism. No signs of inhalation injury (no stridor, hoarseness, soot, singed hairs). Aggressive resuscitation initiated in ED: Two large-bore IVs, warmed LR per pediatric Parkland (total ~500 mL infused to date), forced-air warming, fentanyl boluses/infusion. Good response noted - hemodynamics improving, UOP starting, core temp rising, pain better controlled. Labs consistent with stress response and hypoperfusion (lactate 3.5, mild acidosis). CXR clear. Transferred to PICU @1315 stable with parents at bedside. Accepting for ongoing burn shock management, hypothermia reversal, pain control, and preparation for burn center transfer. Past Medical History: Healthy full-term infant; no chronic conditions. Immunizations UTD. No prior injuries/hospitalizations. Medications: None prior; current - fentanyl infusion, pantoprazole, tetanus administered in ED. Allergies: NKDA. Family/Social History: Lives with attentive parents (Anna and Kevin Chen) in Riverside apartment. No tobacco/alcohol/drug exposure concerns. CPS consulted - initial assessment reassuring (pattern consistent with history; no other injuries). Review of Systems: As per HPI - positive for severe pain (improving), lethargy (resolving), poor perfusion (improving). Negative for respiratory distress, vomiting, seizures. Objective: Vital Signs (trended): ED arrival (T=0): Core Temp 94.0°F, BP 70/40, HR 160, RR 40, SpO2 90% on 100% NRB 60 minutes post-arrival: Core Temp 96.2°F, BP 88/52, HR 145, RR 32, SpO2 95% on 100% NRB Now (PICU admission): Core Temp 97.1°F (rectal), BP 94/56 mmHg, HR 138 bpm, RR 30/min, SpO2 97% on 6 L/min simple mask, Weight 12 kg confirmed. General: Alerting, whimpering intermittently but consoled by parents. Warmer to touch. HEENT: No facial burns; pupils equal/reactive; no soot/stridor. CV: Regular, improved peripheral pulses (2+ bilaterally), cap refill 2-3 sec. Resp: Clear bilaterally, easy effort. Abdomen: Soft, hypoactive BS, non-distended. NG minimal output. Skin/Burns: Dressings intact; TBSA 31% mixed depth unchanged. Splash pattern, irregular margins. No compartment syndrome signs. Neuro: GCS 14-15; moves all extremities, follows simple commands inconsistently. Extremities: Elevated; no jewelry. Lines: Two IVs patent; Foley patent (~20 mL/hr current UOP); NG in place. Labs (repeat on arrival pending; ED labs reviewed): Lactate trending down (repeat sent), CK mild elevation, electrolytes stable. Assessment: 2-year-old previously healthy male with major scald burns (31% TBSA mixed partial/full thickness) complicated by: Resolving burn shock (hypovolemic/distributive) - good response to fluid resuscitation. Resolving profound hypothermia. Severe pain - controlled on fentanyl infusion. Risk for complications (AKI, infection, rhabdo, compartment syndrome). Non-accidental trauma ruled out initially (consistent history/pattern; CPS following). Critical but stabilizing; high-risk for deterioration requiring close monitoring. Plan: Resuscitation: Continue warmed LR per Parkland (~70 mL/hr current first-8-hour phase; total goal 1,116 mL/24h). Titrate strictly to UOP 1-2 mL/kg/hr, hemodynamics, lactate clearance. Avoid overload. Hypothermia: Aggressive warming ongoing (forced-air, warm room/fluids); goal normothermia. Pain/Sedation: Fentanyl infusion 1-2 mcg/kg/hr; bolus PRN. FLACC q15-30min. Respiratory: Wean O2 as tolerated; vigilant for delayed inhalation injury. Wounds: Maintain dry dressings; await Pediatric Burn Surgery bedside eval (Dr. Hayes notified). Monitoring: Continuous cardio-resp, hourly neuro/UOP, q15-30min VS initially. Serial labs q4-6h (CBC, BMP, ABG/lactate, CK). Nutrition/Prophylaxis: NPO; start trophic enteral feeds tomorrow per Nutrition consult. Continue pantoprazole. Consults: Burn Surgery (primary for wound plan/grafting). Child Life (ongoing family support). Social Work/CPS (follow-up). Nutrition (hypermetabolic needs). Family: Frequent updates; support parents' presence. Disposition: Stabilize for transfer to Regional Pediatric Burn Center (likely Day 2). Full code.", "type" : "Physician Notes" }, { "author" : "Taylor Nguyen , Registered Nurse", "dateTime" : "2026-09-25T12:32:00", "id" : "leo-chen-note-7", "summary" : "Received report from ED RN Jennifer Lopez. Patient is a previously healthy 2-year-old male who sustained scald burns ~1145 after pulling a pot of boiling water off the stove. Mechanism witnessed by mother (Anna Chen), who immediately removed wet clothing and called 911. No LOC. NKDA, immunizations UTD. In ED: Aggressive resuscitation initiated with warmed LR per Parkland, fentanyl for pain, and warming measures. Good early response noted (hemodynamics improving, hypothermia resolving slowly). Parents (Anna and Kevin Chen) highly distressed but attentive; both accompanying to PICU and at bedside. Child Life (Sophia Martinez) involved for support. CPS consult (Laura Jenkins, LCSW) completed in ED - no immediate concerns, pattern consistent with accidental splash. Child now calmer with fentanyl infusion; occasional whimpering but resting intermittently between stimuli. Parents report he was \"acting normal\" prior to incident. Placed on continuous monitoring (cardiac, SpO2, ETCO2). Room temp increased to 85°F; forced-air warmer and warmed blankets applied. All fluids warmed. Continuing Parkland resuscitation: Warmed LR @ ~70 mL/hr (first 8-hour phase from burn time). Total infused to date ~450 mL. Titrate strictly to UOP goal 1-2 mL/kg/hr (12-24 mL/hr), hemodynamics, and lactate trend. Pain: Fentanyl continuous infusion @1 mcg/kg/hr running; bolus 1 mcg/kg given on arrival for FLACC 6 during transfer. Reassess q15-30min. Respiratory: Titrated O2 to simple mask; monitor closely q15min initially. Wound: Dressings intact; no changes until burn surgery eval (Dr. Hayes notified of transfer). Labs: Repeat STAT on arrival (CBC, BMP, ABG, lactate, CK) - pending results. Consults active: Burn Surgery, Child Life at bedside, Social Work following up, Nutrition for early feeds planning. Family: Both parents at bedside; oriented to room/unit. Encouraged skin-to-skin (unburned areas) and comfort measures. Emotional support provided. Safety: Bed in lowest position, side rails up, isolation precautions initiated (contact + burn protocol). Upon PICU arrival: Core Temp 96.8°F (rectal probe), BP 92/55 mmHg, HR 140 bpm, RR 30/min, SpO2 96% on 8 L/min via simple mask (titrated down), FLACC 4/10 (grimacing with movement, consoled by parents). Weight confirmed 12 kg. General: Toddler male, pale but warmer to touch. More alert than ED report; eyes open to voice, reaches for mother. Access/Lines: Two IVs patent (22G right AC, 20G left forearm). Foley catheter patent, UOP ~18 mL/hr since insertion (total ~50 mL in ED). NG tube to low suction, minimal drainage. CV: Regular rhythm, improved peripheral pulses (faint but palpable), cap refill 3 sec. Resp: Easy efforts, clear bilaterally, no stridor/hoarseness. Skin/Burns: Burns covered with dry sterile dressings (applied in ED). Estimated 31% TBSA unchanged (anterior torso 12%, left arm circumferential 9%, bilateral thighs 9%, perineum 1%). No increased edema or compartment concerns noted on transfer. Neuro: GCS 14 (E4, V4 crying/consolable, M6). Pupils equal/reactive. Moves all extremities symmetrically. GI/GU: Abdomen soft, non-distended, bowel sounds hypoactive.", "type" : "Nursing - Admission" }, { "author" : "Jennifer Lopez , Registered Nurse", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-note-8", "summary" : "Patient transferred to PICU @ 1315 with bedside nurse Taylor Nguyen, RN, and respiratory therapist. Stable during handoff. Parents aware, in waiting room.", "type" : "Nursing - Transfer" }, { "author" : "Dr. Sarah Ramirez , Admitting Physician", "dateTime" : "2026-09-25T12:12:00", "id" : "leo-chen-note-9", "summary" : "Subjective: Patient remains in ED for ongoing resuscitation. Mother (Anna Chen) at bedside, reports child pulled pot of boiling water down ~1145. No new history. Child less inconsolable after fentanyl boluses; now intermittently whimpering/moaning. Parents highly distressed but cooperative; updated on plan for PICU transfer and burn center referral. No concerns raised for non-accidental trauma at this time (pattern consistent with history). Objective: Vital Signs (trending improvement): 1200 (arrival): Core Temp 94.0°F, BP 70/40, HR 160, RR 40, SpO2 90% on 100% NRB 1230: Core Temp 95.5°F, BP 82/48, HR 152, RR 36, SpO2 93% on 100% NRB, FLACC 7/10 1300 (now): Core Temp 96.2°F (rectal probe), BP 88/52, HR 145, RR 32, SpO2 95% on 100% NRB, FLACC 5/10 (calmer, occasional whimper) General: Toddler male, pale but less cold to touch. More alert, eyes opening to voice, localizing pain. Access: Two large-bore IVs established (22G right AC per EMS; 20G left forearm in unburned skin). Foley inserted ~1245; initial UOP 8 mL over 15 min, now ~15 mL/hr (improving). NG tube inserted, minimal output. CV: Tachycardic but improved; peripheral pulses now faintly palpable distally, cap refill 3-4 sec (was >4 sec). Resp: Decreased work of breathing; clear bilaterally, no stridor/hoarseness/soot. Skin/Burns: TBSA confirmed ~31% mixed depth (anterior torso 12%, left arm circumferential 9%, bilateral thighs 9%, perineum 1%). Burns covered with dry sterile dressings. No escalation in edema noted. Neuro: GCS improved to 13 (E3, V4, M6); more responsive to parents. Labs/Diagnostics (initial STAT results received ~1245): CBC: Hgb 13.0, Hct 39%, WBC 18k (stress) BMP: Na 135, K 4.0, Creat 0.6, Glucose 180 ABG: pH 7.25, PaO2 80, Lactate 3.5 → repeat pending CXR: Clear, no infiltrates ECG: Sinus tachycardia, no ischemia Assessment: 2-year-old male with severe scald burns (31% TBSA mixed partial/full thickness) and initial burn shock/hypothermia. Good early response to aggressive fluid resuscitation (total ~350 mL warmed LR infused since arrival, per Parkland), warming measures, and pain control. Hemodynamics improving (BP trending up, HR down, perfusion better, UOP starting). Hypothermia resolving slowly. No evidence of inhalation injury. Splash pattern consistent with accidental mechanism; CPS consulted per protocol. Remains critical but stabilizing for PICU transfer. Plan: Continue Parkland resuscitation (current rate ~70 mL/hr warmed LR); titrate to UOP goal 1-2 mL/kg/hr and hemodynamics. Ongoing aggressive warming (forced-air blanket, warm room/fluids). Goal core temp >97°F prior to transfer. Pain: Fentanyl continuous infusion initiated @1 mcg/kg/hr; bolus PRN. FLACC reassess q15-30min. Transfer to PICU Room 412A imminent (bed ready; Dr. Thompson accepting). Consults: Pediatric Burn Surgery (Dr. Hayes) - en route for bedside eval. PICU (Dr. Thompson) - accepting and overseeing transfer. Social Work/CPS (Laura Jenkins) - initial interview completed; no immediate concerns. Child Life (Sophia Martinez) - at bedside providing parental support. Repeat labs q4h in PICU; monitor lactate/CK trend. Prepare for burn center transfer once stable (likely tomorrow). Family: Continue updates; both parents to accompany to PICU.", "type" : "Physician Notes" }, { "author" : "Jennifer Lopez , Registered Nurse", "dateTime" : "2026-09-25T11:24:00", "id" : "leo-chen-note-10", "summary" : "Activated pediatric trauma protocol. Placed on continuous monitoring, 100% O2 via NRB. Established one IV (per EMS - right AC, 22G); attempting second large-bore IV. Initiated aggressive warming: removed remaining wet items, applied forced-air warmer, warmed blankets, increased room temp. Warmed all fluids. Fentanyl 1 mcg/kg IV push x1 given for pain - reassess q15min (FLACC). Covered burns with clean dry sterile sheets. Foley and NG tube placement pending PICU transfer. Notified Pediatric Burn Surgery (Dr. Hayes) and PICU Intensivist (Dr. Thompson) - consults pending. Social Work/CPS notified per protocol (Laura Jenkins, LCSW). Mother at bedside, highly distressed - provided emotional support and updates. Preparing for rapid transfer to PICU Room 412A once second IV secured and initial stabilization achieved.", "type" : "Nursing - Progress Note" }, { "author" : "Jennifer Lopez , Registered Nurse", "dateTime" : "2026-09-25T11:12:00", "id" : "leo-chen-note-11", "summary" : "Patient arrived via EMS approximately 15 minutes post-injury. Mother (Anna Chen) reports: \"He pulled the pot of boiling water right off the stove onto himself! I just turned my back for a second!\" Mother states she immediately removed wet clothing, wrapped child in clean towel, and called 911. No loss of consciousness reported. Child too young for verbal history; inconsolable screaming on arrival, progressing to intermittent moaning/lethargy. Denies prior burns or similar injuries. Immunizations UTD per mother. NKDA. Vital Signs (on arrival): Core Temp 94.0°F (34.4°C, rectal), BP 70/40 mmHg, HR 160 bpm (thready), RR 40/min (shallow/irregular), SpO2 90% on 100% NRB mask. GCS 12 (E3, V4 crying/confused, M5 localizes pain). Pain: 10/10 (FLACC scale - inconsolable screaming, rigid posturing). General: Toddler male, pale, cold to touch, lethargic with weak crying. Obvious extensive scald burns with wet skin from initial cooling. HEENT: No singed nasal hairs, no soot in mouth/nares. No facial burns. Pupils equal/reactive. CV: Tachycardic, distant heart sounds. Peripheral pulses absent distally, cap refill >4 sec. Neck veins flat. Resp: Tachypneic, shallow efforts. Clear bilaterally, no stridor/hoarseness. Skin/Burns: Estimated 31% TBSA mixed partial/full thickness scald burns - anterior torso (mixed red/blistered and white/waxy), left arm (circumferential), bilateral thighs (anterior splash), perineum. Irregular splash pattern with blistering and bullae noted. No glove/sock pattern or clear immersion lines. Neuro: Lethargic, follows commands inconsistently, moves all extremities but withdraws from pain. GI/GU: Abdomen soft, bowel sounds diminished. No distension.", "type" : "Nursing - Admission" }, { "author" : "Dr. David Kim , Primary Care Physician", "dateTime" : "2026-09-25T11:12:00", "id" : "leo-chen-note-12", "summary" : "Subjective: Overnight course stable per nursing report. Patient rested intermittently with fentanyl infusion; occasional whimpering with position changes but consoled quickly by parents. Parents (Anna and Kevin Chen) alternated bedside overnight; report feeling \"exhausted but relieved he's more comfortable.\" No new complaints. Tolerating new enteral feeds (trophic rate) without vomiting or high residuals. Child Life and Social Work continuing support. General: Toddler male, resting comfortably, more interactive - tracking parents, brief smiles with Child Life toys. Warmer/normal color. HEENT/Resp: Clear breath sounds, no increased work. O2 weaned to room air overnight. No stridor/hoarseness. CV: Regular, strong peripheral pulses, cap refill <2 sec. Abdomen: Soft, non-distended, active BS. NG residuals low (10-20 mL q4h). Skin/Burns: Dressings clean/dry (initial silver sulfadiazine applied overnight per Burn Surgery). Moderate edema stable. No foul odor or purulence noted on check. Extremities elevated. Neuro: GCS 15; alert, follows simple commands, reaches for parents. I&O (past 12 hours): Intake ~800 mL (Parkland LR transitioned to lower rate + trophic feeds @20 mL/hr). UOP ~25 mL/hr (goal met). Positive balance appropriate. Lines: IVs patent; Foley/NG patent. Labs (q6h overnight and AM draw): CBC: Hgb 11.8 (mild drop, expected), WBC 15k (downtrending). BMP: Electrolytes stable (K 3.8 with repletion), Creat 0.6 (stable), Glucose 130 (improving). Lactate: 1.2 (normalized). CK 400 (peaking, monitor). ABG not repeated (stable). Assessment: 2-year-old male, Hospital Day 2, s/p major scald burns (31% TBSA mixed depth) now ~21 hours post-injury. Burn shock resolved - excellent response to Parkland resuscitation (hemodynamics normalized, lactate cleared, UOP robust). Hypothermia resolved. Pain well-controlled; tolerating early enteral nutrition. Wounds stable with initial topical therapy; no early infection signs. Psychosocial: Family coping with support; accidental mechanism confirmed. Overall stable and improving; appropriate for transfer to specialized Pediatric Burn Center today if bed available. Plan: Fluids/Nutrition: Complete Parkland (second 16-hour phase ending soon); transition to maintenance + enteral needs. Advance tube feeds as tolerated per Nutrition (target full goal rate today). Monitor glucose/electrolytes closely. Pain/Sedation: Continue fentanyl infusion; wean as FLACC allows. Add acetaminophen PRN. Wound Care: Daily cleansing/topical antimicrobials per Burn Surgery (Dr. Hayes rounding today). Monitor circumferential areas. Respiratory: Room air; continue monitoring for delayed issues. Monitoring/Labs: q6h VS/labs today; daily weights. Serial CK/lactate. Prophylaxis: Continue pantoprazole; no antibiotics. Rehabilitation/Support: Early PT/OT consult today for positioning/splinting. Continue Child Life daily; Social Work follow-up. Disposition: Actively coordinate transfer to Regional Pediatric Burn Center (bed confirmed pending). Parents educated on plan; excited for specialized care. Full code. Multidisciplinary rounds completed with nursing, Burn Surgery, Nutrition, Child Life, and Social Work. Family updated and questions answered.", "type" : "Physician Notes" }, { "id" : "leo-chen-section-immunizations", "summary" : " Birth to Adult Immunizations: Td/Tdap, Varicella, MMR 1, MMR 2, Rubella, Polio, Hepatitis B\n Titers: N/A\n9/25/2026 11:27 | Birth to Adult Immunizations: Td/Tdap, Varicella, MMR 1, MMR 2, Rubella, Polio, Hepatitis B Titers: N/A", "type" : "Immunizations" }, { "id" : "leo-chen-section-current-care-providers", "summary" : "Alicia Brooks | Physical Therapy\nCarlos Rivera | Respiratory Therapy\nDr. David Kim | Primary Care Physician\nDr. Emily Thompson | Primary Care Physician\nDr. Kevin Singh | Pharmacy\nDr. Michael Patel | Consulting Physician\nDr. Robert Hayes | Consulting Physician\nDr. Sarah Ramirez | Admitting Physician\nJennifer Lopez | Registered Nurse\nJordan Lee | Occupational Therapy\nLaura Jenkins | Social Services\nMaria Gonzalez | Patient Access Specialist\nMegan Walsh | Dietary/Nutrition\nSophia Martinez | Child Life Specialist\nTaylor Nguyen | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "leo-chen-clarification-18", "summary" : "Source says immunizations are up to date but orders tetanus toxoid without age-appropriate product or verified series dates; later narrative says already administered. Clarify before another dose. CDC wound guidance does not indicate another vaccine when primary series is complete and last dose was less than five years ago. Reference: https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html", "type" : "Chart clarification" }, { "id" : "leo-chen-clarification-19", "summary" : "Source timeline reconciliation required: a hospital-day-2 physician note is timestamped at admission, and literal injury/transfer clock times conflict with relative timestamps. Later fentanyl infusion, pantoprazole and topical therapy appear in narrative without matching structured medication orders; no active orders fabricated. Kiwi angioedema is a food allergy and retained alongside NKDA statements. Neutropenic/leukopenic isolation label conflicts with contact/burn-protocol narrative; no neutropenia inferred.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-1", "orderText" : "Admit to Pediatric Intensive Care Unit (PICU) Room 412A as Level 1 (critical) for aggressive resuscitation and monitoring; x1 (1 time only), 1 time only; Routine; Accepting MD: Dr. Emily Thompson, MD (PICU Intensivist) Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-2", "orderText" : "Continuous cardiac monitoring, SpO2, ETCO2/capnography.; cont.; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-3", "orderText" : "Vital signs q15min x4, then q30min until stable. Manual BP and peripheral pulse checks with each set.; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-4", "orderText" : "Continuous core temperature monitoring; cont.; Routine; (rectal probe). Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-5", "orderText" : "Strict hourly intake/output via Foley catheter; cont.; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-6", "orderText" : "Hourly neuro checks; q1h (Every 1 hour), Every 1 hour; Routine; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-7", "orderText" : "NPO; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-8", "orderText" : "Establish TWO large-bore IVs STAT (prefer unburned skin; IO if needed); x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-9", "orderText" : "Fluid resuscitation; x1 (1 time only), 1 time only; Stat; Lactated Ringer's (warmed) per pediatric Parkland formula. TBSA: 31% Weight: 12 kg Calculation: 3 mL × 31 × 12 = 1,116 mL total over 24 hours from time of injury (~1145). First 8 hours (~1145-1945): 558 mL total (~70 mL/hr). Next 16 hours: 558 mL total (~35 mL/hr). Titrate to urine output goal 1-2 mL/kg/hr (12-24 mL/hr). Additional boluses (10-20 mL/kg warmed LR) PRN for persistent hypotension/poor perfusion. All IV fluids via fluid warmer. Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:12:00", "id" : "leo-chen-order-10", "orderText" : "Warmed Humidified Oxygen: 100% via non-rebreather mask (or blow-by if not tolerated); titrate to SpO2 ≥95%; cont.; Routine; Source due: 9/25/2026 11:12", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-11", "orderText" : "Monitor closely for inhalation injury (q15min respiratory assessment). Prepare for intubation if stridor, increased work of breathing, or GCS decline.; cont.; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-12", "orderText" : "Warming Measures (Hypothermia Protocol); x1 (1 time only), 1 time only; Stat; Aggressive external warming STAT: Forced-air warming blanket (full body). Warmed blankets and radiant warmer. Increase ambient room temperature to 85-90°F. All fluids/irrigation warmed. Goal: Core temp >96.8°F within 1-2 hours. Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-13", "orderText" : "Wound Care; x1 (1 time only), 1 time only; Stat; Cover burns with clean, dry sterile sheets/dressings immediately (non-adherent if available). NO topical agents or ice in ED. Remove all jewelry/constrictive items. Elevate burned extremities. Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-14", "orderText" : "Labs; q6h x1 (Every 6 hours, 1 time only), Every 6 hours, 1 time only; Stat; CBC, BMP, ABG, lactate, CK, and coagulation studies. Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-15", "orderText" : "type & screen; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:12:00", "id" : "leo-chen-order-16", "orderText" : "Code Status: Full Code; cont.; Stat; Source due: 9/25/2026 11:12", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-17", "orderText" : "Allow both parents (Anna and Kevin Chen) at bedside with support. Update q30min.; cont.; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-18", "orderText" : "Consult: Pediatric Critical Care; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-19", "orderText" : "Consult: Child Life Specialist; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-20", "orderText" : "Consult: Social Work; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Not specified", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-21", "orderText" : "Consult: Nutrition; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-22", "orderText" : "Vital signs: q15min x4 hours, then q30min x4 hours, then q1h if stable. Include manual BP, peripheral pulses, and cap refill with each set.; cont.; Routine; Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-23", "orderText" : "Continuous cardiac monitoring, SpO2, ETCO2/capnography.; cont.; Routine; Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-24", "orderText" : "Continuous core temperature monitoring (rectal probe).; cont.; Routine; Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-25", "orderText" : "Strict hourly intake/output via Foley catheter.; cont.; Routine; Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-26", "orderText" : "Hourly neuro checks (GCS, pupils) x8 hours, then q2h; x1 (1 time only), 1 time only; Routine; Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-27", "orderText" : "Daily weights AM; cont.; Routine; Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-28", "orderText" : "Bedrest with extremities elevated; cont.; Routine; Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-29", "orderText" : "NPO initially; initiate trophic enteral feeds tonight/morning per Nutrition consult; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-30", "orderText" : "Place NG/OG if not present; x1 (1 time only), 1 time only; Routine; Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-31", "orderText" : "Chest Xray; x1 (1 time only), 1 time only; Routine; Confirm NG/OG placement Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-32", "orderText" : "Pain Management & Sedation; x1 (1 time only), 1 time only; Routine; Fentanyl IV: Continuous infusion 1-2 mcg/kg/hr (current running); bolus 1 mcg/kg IV q15-30min PRN severe pain. Acetaminophen 15 mg/kg PO/PR q6h PRN mild pain/fever (once feeds tolerated). Reassess pain q15-30min using FLACC scale (goal ≤4). Non-pharmacologic: Parental presence, Child Life distraction mandatory. Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-33", "orderText" : "Warming Measures; x1 (1 time only), 1 time only; Routine; Continue hypothermia reversal protocol: Forced-air warming blanket, warmed blankets, warm room (85-90°F), all fluids warmed. Goal: Core temp 98-99°F; taper as normothermic. Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-34", "orderText" : "Wound Care; q24h (Every 24 hours), Every 24 hours; Stat; Maintain clean dry sterile dressings until Burn Surgery full eval. Initiate daily wound cleansing and topical antimicrobial (silver sulfadiazine 1% cream) starting tonight/tomorrow per Burn Surgery. Elevate burned extremities; monitor circumferential areas q1h for pulses/cap refill. Escharotomy PRN if compromise. Strict contact isolation + burn protocol (hand hygiene, gloves/gown for dressing changes). Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Emily Thompson, Primary Care Physician", "category" : "Not specified", "dateTime" : "2026-09-25T12:27:00", "id" : "leo-chen-order-35", "orderText" : "Labs; x1 (1 time only), 1 time only; Stat; STAT on admission: CBC, BMP, ABG, lactate, CK, coagulation studies. Serial labs: q4-6h x24 hours (CBC, BMP with focus on Na/K/Creat/Glucose, lactate, CK). Then q12h. Daily AM labs thereafter. Indirect calorimetry when stable. Source due: 9/25/2026 12:27", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Consult", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-36", "orderText" : "Consult: Pediatric Burn Surgeon; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:14", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-37", "orderText" : "Fluid resuscitation: Lactated Ringer's (warmed) per pediatric Parkland formula. 70 mL/hr IV, first 8-hour phase from burn time. Warmed Source due: 9/25/2026 11:14 Sequential resuscitation phases, not simultaneous infusions. Confirm burn time, prior infused volume and maintenance needs; titration per source urine-output/hemodynamic instructions.", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-38", "orderText" : "Fluid resuscitation: Lactated Ringer's (warmed) per pediatric Parkland formula. 35 mL/hr IV, subsequent 16-hour phase; not concurrent with first phase. Warmed Source due: 9/25/2026 19:12 Sequential resuscitation phases, not simultaneous infusions. Confirm burn time, prior infused volume and maintenance needs; titration per source urine-output/hemodynamic instructions.", "status" : "Active" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-39", "orderText" : "Tetanus toxoid; 0.5ml Intramuscular (IM); x1 (1 time only), 1 time only; Scheduled, Stat; Immunizations UTD per mother, but administer per burn protocol Source due: 9/25/2026 11:14 Source says immunizations are up to date but orders tetanus toxoid without age-appropriate product or verified series dates; later narrative says already administered. Clarify before another dose. CDC wound guidance does not indicate another vaccine when primary series is complete and last dose was less than five years ago. Reference: https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html", "status" : "Held — clarification required" }, { "author" : "Dr. Sarah Ramirez, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T11:14:00", "id" : "leo-chen-order-40", "orderText" : "Fentanyl; 1mcg/kg Intravenous (IV); q15min (Every 15 minutes), Every 15 minutes; PRN; Reassess pain q15-30min using FLACC scale (goal ≤4) Source due: PRN", "status" : "Active" } ], "overview" : { "height" : "34.5 in / 87.6 cm", "isolationIndicator" : "Neutropenic/Leukopenic", "religion" : "Buddhist", "weightKg" : 12 }, "vitals" : [ { "bloodPressure" : "70/40", "dateTime" : "2026-09-25T11:14:00", "heartRate" : 160, "id" : "leo-chen-vital-1", "spo2" : "90", "temperature" : "94 °F (34 °C), 34 °C" }, { "bloodPressure" : "92/55", "dateTime" : "2026-09-25T12:27:00", "heartRate" : 140, "id" : "leo-chen-vital-2", "oxygenDevice" : "Simple Face Mask", "respiratoryRate" : 30, "spo2" : "96", "temperature" : "96.8 °F (36 °C), 36 °C Core" }, { "bloodPressure" : "95/58", "dateTime" : "2026-09-25T13:12:00", "id" : "leo-chen-vital-3", "oxygenDevice" : "Simple Face Mask", "respiratoryRate" : 29, "spo2" : "97", "temperature" : "97.2 °F (36 °C), 36 °C Core" }, { "bloodPressure" : "98/60", "dateTime" : "2026-09-25T14:12:00", "heartRate" : 135, "id" : "leo-chen-vital-4", "oxygenDevice" : "Simple Face Mask", "respiratoryRate" : 28, "spo2" : "97", "temperature" : "97.8 °F (37 °C), 37 °C Core" }, { "bloodPressure" : "100/62", "dateTime" : "2026-09-25T15:12:00", "heartRate" : 130, "id" : "leo-chen-vital-5", "oxygenDevice" : "Simple Face Mask", "respiratoryRate" : 27, "spo2" : "98", "temperature" : "98.4 °F (37 °C), 37 °C Core" }, { "bloodPressure" : "101/63", "dateTime" : "2026-09-25T16:12:00", "heartRate" : 128, "id" : "leo-chen-vital-6", "oxygenDevice" : "Simple Face Mask", "respiratoryRate" : 27, "spo2" : "98", "temperature" : "98.4 °F (37 °C), 37 °C Core" }, { "bloodPressure" : "102/64", "dateTime" : "2026-09-25T17:12:00", "heartRate" : 125, "id" : "leo-chen-vital-7", "oxygenDevice" : "Nasal Cannula", "spo2" : "98", "temperature" : "98.5 °F (37 °C), 37 °C Core" } ] }, "patient" : { "admitDateTime" : "2026-09-25T11:12:00", "admittingDiagnosis" : "Burns, pediatric", "allergies" : [ { "id" : "allergy-ac8e6201d004f520", "reaction" : "Angioedema", "severity" : "Not documented", "substance" : "Kiwi" } ], "attending" : "Dr. Sarah Ramirez, Admitting Physician", "chartDisplayName" : "Chen, Leo", "codeStatus" : "Full Code", "dob" : "2/10/XX", "history" : { "chiefComplaint" : "Leo Chen, a previously healthy 2-year-old, pulled a pot of boiling water off the stove, sustaining scald burns to his anterior torso, left arm, bilateral thighs, and perineum. His mother immediately removed wet clothing and called 911. On ED arrival, Leo presents in severe pain progressing to lethargy, with signs of burn shock (hypotension, tachycardia) and profound hypothermia. Estimated TBSA: 31% (mixed partial- and full-thickness).", "pastMedicalHistory" : [ "General Medical History: Denies prior medical problems", "General Medical History / Notes: Previously healthy toddler with no chronic illnesses, hospitalizations, surgeries, or prior injuries (including no previous burns or trauma). Birth history: Full-term, uncomplicated delivery; no neonatal issues. Immunizations: Fully up-to-date. Medications: None. Allergies: NKDA. Development: Meeting all milestones appropriately.", "Transfusion History / Previous Blood Transfusion?: No", "Transfusion History / Does Patient Know His/Her Blood Type?: No", "Pain History / History of Chronic Pain?: No" ], "pastSurgicalHistory" : [ "Previous Surgical Procedures: No prior surgical history" ], "socialHistory" : [ "Age: 2 years", "Home Situation / Relationship / Relationship: Mother", "Home Situation / Name / Name: Anna Mei Chen", "Home Situation / Primary Residence?: Primary Residence?", "Home Situation / Relationship / Relationship: Father", "Home Situation / Name / Name: Kevin Jian Chen", "Home Situation / Primary Residence?: Primary Residence?", "Home Situation / Emancipated Minor?: No", "Education / Enrolled in School?: No", "Environmental Home Assessment Help - What Environmental Home Assessment means / Type of Dwelling: Rental", "Environmental Home Assessment Help - What Environmental Home Assessment means / Age of Home: Don’t know", "Environmental Home Assessment Help - What Environmental Home Assessment means / Type of Heat: Natural gas", "Environmental Home Assessment Help - What Environmental Home Assessment means / Lead Paint: Not tested/Don’t know", "Environmental Home Assessment Help - What Environmental Home Assessment means / Radon: Not tested/Don’t know", "Environmental Home Assessment Help - What Environmental Home Assessment means / Drinking Water Source: Public water system", "Nicotine Use / Is patient exposed to second-hand smoke?: No", "Alcohol Use / Any Alcohol Use in the Home?: Unknown", "Drug Use / Any Drug Use in the Home?: Unknown", "Violence Screening / Any History of Violence in the Home?: Unknown", "Violence Screening / Has Anyone Ever Hurt Patient Emotionally, Physically, or Sexually?: Unknown", "Nutritional Screening / Recent Weight Lost Without Trying?: Unknown", "Nutritional Screening / Does patient have diabetes?: No", "Nutritional Screening: Vegetarian", "Nutritional Screening / Stool Frequency: daily", "Nutritional Screening / Stool Description: Formed", "Nutritional Screening / Last Bowel Movement Days: 0", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment", "Nutritional Screening / Notes: Last night", "Other Safety Measures / Seatbelt/Carseat Use?: Always", "Other Safety Measures / Working Smoke Detectors in the Home?: Yes", "Other Safety Measures / Working Carbon Monoxide Detectors in the Home?: Yes", "Other Safety Measures / Working Fire Extinguisher in the Home?: Yes" ] }, "mrn" : "10242678", "sex" : "Male", "simulatedFullName" : "Leo Chen", "unit" : "RCC Hospital — Room 412 — Bed A" }, "setting" : "RCC Hospital — Room 412 — Bed A", "snapshots" : [ { "activityIds" : [ ], "id" : "leo-chen-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2026-09-25T12:06:00", "sourcePath" : "DocuCare instructor chart: Leo Chen", "title" : "Captured chart" } ], "subtitle" : "N22 practice record", "tags" : [ "N22", "DocuCare migration" ], "title" : "Leo Chen" }, "packageId" : "docucare-n22-leo-chen-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated educational record only. Not for clinical care. Review the chart and faculty directions before practice." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "n22-leo-chen", "instructions" : "Open the assigned patient chart. Confirm name, DOB and MRN; review allergies, notes, vitals, labs, orders and the MAR. Discuss missing or conflicting information with faculty. Held and discontinued medications are for review and are not active administration tasks. Scenario dates are historical. Follow your faculty directions.", "title" : "Leo Chen" } ], "format" : "org.chartslate.case-collection", "id" : "docucare-n22-course-review-v1", "summary" : "Five N22 simulated patient charts in one download. Choose a patient after importing the bundle. Records are available offline after import.", "title" : "N22", "version" : 1 }