62-year-old female with obesity hypoventilation syndrome, COPD, CHF, sleep apnea (CPAP with 4L O₂) brought BIBA from ALF after caregiver found her unresponsive. CPAP mask was on face but disconnected from O₂ source; machine and mask covered in vomit. EMS applied sternal rub to arouse. Scene SpO₂ on RA: 80%. Patient fully alert and oriented upon ED arrival. Denies fevers, chills, diarrhea, cough.
| Date/Time | Temp | HR | RR | BP | MAP | SpO₂ | O₂ Delivery | Pain |
|---|---|---|---|---|---|---|---|---|
| 02/11 2210 (Scene) | — | — | — | — | — | 80% | Room Air | — |
| 02/11 2218 (ED Admit) | 38.2°C | 102 | 24 | 88/54 | 65 | 80% | 4L NC + BiPAP | 0/10 |
| 02/11 2235 | — | 77 | 21 | 123/95 | — | 98% | 4L NC | 0/10 |
| 02/12 0000 | — | 68 | 15 | 125/105 | 112 | 100% | 4L NC | 0/10 |
| 02/12 0335 | — | 83 | 23 | 138/108 | 118 | 96% | 4L NC | 0/10 |
| 02/12 0530 | 36.6°C | 86 | 17 | 107/64 | 78 | 98% | BiPAP | 0/10 |
ℹ Ht: 5'4" · Wt: 163 kg · BMI: 61.8 · MAP ≥65 required · VS ordered Q2H
| Test | Reference | Result | Flag | Clinical Significance |
|---|---|---|---|---|
| HEMATOLOGY — CBC — Drawn 02/11 2225 | ||||
| WBC | 4.5–10.7 x10³/uL | 12.9 | H | Elevated — active immune response; bacterial UTI |
| RBC | 3.50–5.50 xMIL/uL | 3.53 | WNL | |
| Hemoglobin | 12.0–15.0 g/dL | 9.7 | L | Mild anemia; impairs O₂ delivery compounded by COPD |
| Hematocrit | 36–45% | 34 | L | Correlates with mild anemia |
| MCV | 81–99 fL | 96 | WNL | |
| MCHC | 32–36 g/dL | 29 | L | Mild hypochromia |
| Platelets | 130–400 x10³/uL | 264 | WNL | |
| Neutrophils % | 54.0–70.0% | 86.1 | H | Left shift — supports active bacterial infection |
| Lymphocytes % | 30.0–45.0% | 8.1 | L | Relative lymphopenia |
| CHEMISTRY — CMP — Drawn 02/11 2225 | ||||
| Sodium (Na⁺) | 136–144 mmol/L | 140 | WNL | |
| Potassium (K⁺) Initial | 3.6–5.1 mmol/L | 5.9 | HH ‼ | CRITICAL — Severe hyperkalemia. Dysrhythmia risk. |
| Potassium (K⁺) Repeat | 3.6–5.1 mmol/L | 4.8 | WNL | Drawn 0500 — Trending ↓ 5.9→4.8 ✓ [Repeat ordered 0230; drawn 0500 — 30 min late] |
| Chloride (Cl⁻) | 101–111 mmol/L | 97 | L | Consistent with chronic CO₂ retention |
| CO₂ (Serum Bicarb) | 22–32 mmol/L | 36 | H | Chronic renal compensation |
| BUN | 8–26 mg/dL | 49 | H | Reduced renal perfusion (CHF) |
| Creatinine | 0.6–1.1 mg/dL | 0.9 | WNL | |
| eGFR (MDRD) | >60 | 62.8 | WNL | Borderline — pharmacist review required |
| Glucose (Initial) | 70–110 mg/dL | 122 | H | Mild stress hyperglycemia |
| Glucose POC (0426) | 70–120 mg/dL | 116 | WNL | Post D50/Insulin — no hypoglycemia ✓ |
| Albumin | 3.5–5.0 g/dL | 3.6 | WNL | Low-normal — malnutrition risk |
| Ammonia (NH₃) | 9–35 umol/L | 44 | H | Mildly elevated — monitor for encephalopathy |
| COAGULATION | ||||
| PT | 12.1–14.5 sec | 12.9 | WNL | |
| INR | <1.2 | 1.0 | WNL | |
| APTT | 24–33 sec | 26 | WNL | |
| CARDIAC / TOXICOLOGY | ||||
| Troponin I (High Sens) | 0–40 pg/mL | 4 | WNL | Pertinent Negative — no MI ✓ |
| Lactate | <2 mmol/L | 0.8 | WNL | Pertinent Negative — no septic shock ✓ |
| Salicylates | 0–30 mg/dL | <4 | WNL | Negative |
| Ethyl Alcohol | <0.005 g% | <0.005 | WNL | Negative |
| Drug | Dose / Route / Time | Hypothesis Addressed | Patient Response | Status |
|---|---|---|---|---|
| Calcium Gluconate | 1 gm IV STAT — 02/12 0230 | H#1 — Membrane stabilization | NSR maintained. No widened QRS. | DC 0231 |
| Insulin Human Regular Novolin R |
10 units IV STAT — 02/12 0230 | H#1 — Shift K⁺ intracellularly | K⁺ 5.9 → 4.8 ✓ | DC 0231 |
| Dextrose 50% (D50W) | 50 mL IV BOLUS — 02/12 0230 | H#1 — Prevent hypoglycemia | POC glucose 116 mg/dL at 30 min. | DC 0404 |
| Furosemide (Lasix) | 40 mg IV STAT — 02/12 0230 | H#1 (renal K⁺ excretion) + CHF | UO increased 250 mL first hour. | DC 0302 |
| Sodium Bicarbonate | 50 mEq IV STAT — 02/12 0230 | H#2 — Respiratory acidosis | RR unlabored at 17. | DC 0427 |
| Piperacillin/Tazobactam Zosyn — allergy-safe ✓ |
3.375 g IV STAT — 02/12 0242 | H#3 — Active UTI | Tolerated. IV site patent. | DC 0311 |
| Kayexalate / Patiromer Bowel assessment: Not documented |
10 gm PO-Liquid — 02/12 0230 | H#1 — GI K⁺ excretion | Swallowed without difficulty. | DC 0301 |
| Drug | Dose / Route / Frequency | Category / Notes |
|---|---|---|
| Furosemide (Lasix) | 40 mg PO Daily | Loop Diuretic — CHF/Edema |
| Levothyroxine (Levothroid) | 0.2 mg PO Daily AC | Thyroid Hormone |
| Benazepril HCl | 10 mg PO Daily | ACE Inhibitor — HTN · ⚠ May worsen hyperkalemia |
| Gabapentin (Neurontin) | 300 mg PO Q8H | Neuropathic Pain |
| Baclofen (Lioresal) | 10 mg PO Q6H | Muscle Relaxant |
| Doxycycline Hyclate (Vibramycin) | 100 mg PO BID | Antibiotic |
| Dexamethasone (Decadron) | 6 mg PO Daily | Corticosteroid · ⚠ May worsen stress hyperglycemia |
| Famotidine (Pepcid) | 40 mg PO BID | H₂ Blocker — GI protection |
| Potassium Chloride (KCl) | PO Daily | Electrolyte · HOLD — K⁺ 5.9 |
| Acetaminophen (Tylenol) | 4 GM PO PRN Pain | Analgesic · No frequency limit documented |
| Multivitamin | PO Daily | Supplement |
⚠ GFR 62.8 = reduced renal clearance. ACE-I + Dexamethasone require pharmacist reconciliation pre-discharge.
| # | Date/Time | Order | Category | Provider | Status |
|---|---|---|---|---|---|
| 1 | 02/11 2225 | Continuous Cardiac Monitor — telemetry with rhythm strip Q2H | Monitoring | Dr. A. Martinez | Active |
| 2 | 02/11 2225 | Pulse Oximetry — Continuous | Monitoring | Dr. A. Martinez | Active |
| 3 | 02/11 2225 | Vital Signs Q2H | Monitoring | Dr. A. Martinez | Active |
| 4 | 02/11 2210 | Oxygen Administration — 4L/min Nasal Cannula (COPD target SpO₂ 88–92%) | Respiratory | Dr. A. Martinez | Active |
| 5 | 02/11 2225 | Insert Peripheral IV Line — 22G right forearm | Procedure | Dr. A. Martinez | Complete |
| 6 | 02/11 2225 | CBC with Differential | Lab | Dr. A. Martinez | Complete |
| 7 | 02/11 2225 | CMP (BMP + hepatic panel) | Lab | Dr. A. Martinez | Complete |
| 8 | 02/12 0241 | Blood Culture x2 — Bilateral Venipuncture | Microbiology | Dr. A. Martinez | Pending |
| 9 | 02/12 0230 | Calcium Gluconate 1 gm IV — STAT | Medication | Dr. A. Martinez | Complete |
| 10 | 02/12 0230 | Insulin Regular 10 units IV — STAT | Medication | Dr. A. Martinez | Complete |
| 11 | 02/11 2225 | High Fall Risk Precautions — bed lowest, wheels locked, bed alarm, call light | Safety | Dr. A. Martinez | Active |
| 12 | 02/11 2225 | Strict Intake & Output (I&O) — Hourly Documentation | Nursing | Dr. A. Martinez | Active |
| 13 | 02/12 0230 | Repeat BMP in 2 hours — following hyperkalemia cocktail | Lab | Dr. A. Martinez | Complete |
| 14 | 02/11 2225 | Foley Catheter Insertion — strict I&O, urine C&S | Procedure | Dr. A. Martinez | Complete |
| 15 | 02/11 2225 | BiPAP — 10/5 cmH₂O — CO₂ retention / OHS | Respiratory | Dr. A. Martinez | Active |
ℹ Active = ongoing | Complete = executed | Pending = awaiting results
S: K.P.O., 62yo female, admitted 02/11 2215 for ALOC secondary to CO₂ narcosis from disconnected CPAP. Now stable and neurologically intact (AOx4).
B: OHS, Sleep Apnea, COPD, CHF, HTN. Allergies: Cephalosporins (Rash), Sulfonamides (Rash). Full Code. ALF resident.
A: Neuro AOx4. SpO₂ 94% on BiPAP. HR 78, BP 118/72. Foley — 820 mL UO this shift. K⁺ repeat 4.8 ✓. Blood cultures pending.
R: Continue telemetry, strict I&O, BiPAP compliance. Await repeat ABG, cultures.
Reassessment: Patient markedly improved. AOx4 as of 0550. Hemodynamically stable. SpO₂ 94% on BiPAP.
Hyperkalemia: Repeat K⁺ 0500 = 4.8 mEq/L ✓. KCl HOLD — do not resume until repeat BMP.
Infection: Zosyn dose 1 complete. Cultures pending. No fever at 0600. Ammonia mildly elevated but within normal limits — will monitor.
0228: Lab called with critical K⁺ 5.9 mEq/L. Dr. Martinez paged STAT. Callback 0230. VOPO orders — read back confirmed.
0242: All STAT medications obtained from Pyxis, verified against MAR, administered in sequence. Two identifiers confirmed. No adverse reactions.
Arrival 2215. Patient received from EMS. Scene: CPAP disconnected from O₂. SpO₂ 80% on scene.
Initial VS (2218): BP 88/54 | HR 102 irregular | RR 24 | Temp 38.2°C | SpO₂ 80%→88% (4L NC + BiPAP)
Allergies Verified: Cephalosporins (Rash), Sulfonamides (Rash) — armband placed.
Procedure: Straight catheter inserted for urine sample — cloudy amber urine. UA/C&S sent.
Labs Drawn 2225: CBC, CMP, UA/C&S, Troponin, Ammonia, ETOH/Tox, Lactate — sent to lab.
MD Notification: Dr. Martinez notified 2220. Orders received and transcribed.
0720: AOx4. GCS 15. Conversational.
Ammonia: Mildly elevated — within normal limits per provider note. Continue to monitor.
0720: SpO₂ 94% on BiPAP. RR 17, unlabored. Equal bilateral breath sounds.
0720: HR 78 regular. BP 118/72. +2 pitting edema bilateral LE. NSR on telemetry.
| Parameter | Result | Reference | Flag |
|---|---|---|---|
| Urine Color | Amber/Cloudy | Yellow/Clear | H |
| Urine Nitrite | POSITIVE | Negative | H ‼ |
| Leukocyte Esterase | NEGATIVE | Negative | WNL |
| WBC (micro) | 12–15 | 0–5 /hpf | H |
| Bacteria | Many | None | HH |
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