158 lines
21 KiB
JSON
158 lines
21 KiB
JSON
{
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"orders": [
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{ "code": "iv_access", "canonicalName": "Peripheral intravenous access", "category": "procedure", "aliases": ["iv", "intravenous line"], "defaultTurnaroundMinutes": 0, "availableLocations": ["emergency_department", "icu"], "displayRoute": "Peripheral IV", "displayFrequency": "Once", "resultSection": "treatment" },
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{ "code": "cardiac_monitor", "canonicalName": "Continuous cardiac monitoring", "category": "monitoring", "aliases": ["telemetry", "cardiac monitor"], "defaultTurnaroundMinutes": 0, "availableLocations": ["emergency_department", "icu"], "displayRoute": "", "displayFrequency": "Continuous", "resultSection": "treatment" },
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{ "code": "pulse_oximetry", "canonicalName": "Continuous pulse oximetry", "category": "monitoring", "aliases": ["pulse ox", "oxygen saturation"], "defaultTurnaroundMinutes": 0, "availableLocations": ["emergency_department", "icu"], "displayRoute": "", "displayFrequency": "Continuous", "resultSection": "treatment" },
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{ "code": "normal_saline_bolus", "canonicalName": "0.9% sodium chloride intravenous bolus", "category": "medication", "aliases": ["normal saline", "isotonic saline", "fluid bolus"], "defaultTurnaroundMinutes": 0, "availableLocations": ["emergency_department", "icu"], "displayRoute": "IV", "displayFrequency": "Bolus", "resultSection": "treatment" },
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{ "code": "balanced_crystalloid_bolus", "canonicalName": "Balanced crystalloid intravenous bolus", "category": "medication", "aliases": ["lactated ringers", "ringer lactate", "iv fluids"], "defaultTurnaroundMinutes": 0, "availableLocations": ["emergency_department", "icu"], "displayRoute": "IV", "displayFrequency": "Bolus", "resultSection": "treatment" },
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{ "code": "bmp", "canonicalName": "Basic metabolic panel", "category": "laboratory", "aliases": ["electrolytes", "chemistry", "potassium", "creatinine"], "defaultTurnaroundMinutes": 12, "availableLocations": ["emergency_department", "icu", "ward"], "displayRoute": "Blood", "displayFrequency": "Once", "resultSection": "lab" },
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{ "code": "venous_blood_gas", "canonicalName": "Venous blood gas", "category": "laboratory", "aliases": ["vbg", "venous ph"], "defaultTurnaroundMinutes": 8, "availableLocations": ["emergency_department", "icu"], "displayRoute": "Venous blood", "displayFrequency": "Once", "resultSection": "lab" },
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{ "code": "beta_hydroxybutyrate", "canonicalName": "Serum beta-hydroxybutyrate", "category": "laboratory", "aliases": ["ketones", "serum ketones", "bohb"], "defaultTurnaroundMinutes": 15, "availableLocations": ["emergency_department", "icu", "ward"], "displayRoute": "Blood", "displayFrequency": "Once", "resultSection": "lab" },
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{ "code": "cbc", "canonicalName": "Complete blood count", "category": "laboratory", "aliases": ["cbc", "blood count"], "defaultTurnaroundMinutes": 12, "availableLocations": [], "displayRoute": "Blood", "displayFrequency": "Once", "resultSection": "lab" },
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{ "code": "urinalysis", "canonicalName": "Urinalysis", "category": "laboratory", "aliases": ["urine test", "ua"], "defaultTurnaroundMinutes": 15, "availableLocations": [], "displayRoute": "Urine", "displayFrequency": "Once", "resultSection": "lab" },
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{ "code": "pregnancy_test", "canonicalName": "Serum beta-hCG pregnancy test", "category": "laboratory", "aliases": ["pregnancy test", "hcg"], "defaultTurnaroundMinutes": 15, "availableLocations": [], "displayRoute": "Blood", "displayFrequency": "Once", "resultSection": "lab" },
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{ "code": "ecg", "canonicalName": "12-lead electrocardiogram", "category": "diagnostic", "aliases": ["ekg", "electrocardiogram"], "defaultTurnaroundMinutes": 10, "availableLocations": ["emergency_department", "icu", "ward"], "displayRoute": "", "displayFrequency": "Once", "resultSection": "other_test" },
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{ "code": "insulin_infusion", "canonicalName": "Regular insulin intravenous infusion", "category": "medication", "aliases": ["insulin drip", "iv insulin", "regular insulin"], "defaultTurnaroundMinutes": 0, "availableLocations": ["emergency_department", "icu"], "displayRoute": "IV", "displayFrequency": "Continuous", "resultSection": "treatment" },
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{ "code": "potassium_chloride_iv", "canonicalName": "Potassium chloride added to intravenous fluid", "category": "medication", "aliases": ["potassium replacement", "kcl", "replace potassium"], "defaultTurnaroundMinutes": 0, "availableLocations": ["emergency_department", "icu"], "displayRoute": "IV", "displayFrequency": "Continuous", "resultSection": "treatment" },
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{ "code": "dextrose_half_normal_saline", "canonicalName": "Dextrose 5% in 0.45% sodium chloride", "category": "medication", "aliases": ["d5 half normal", "dextrose fluid", "d5 0.45 saline"], "defaultTurnaroundMinutes": 0, "availableLocations": ["emergency_department", "icu"], "displayRoute": "IV", "displayFrequency": "Continuous", "resultSection": "treatment" },
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{ "code": "sodium_bicarbonate_iv", "canonicalName": "Intravenous sodium bicarbonate", "category": "medication", "aliases": ["bicarbonate", "bicarb"], "defaultTurnaroundMinutes": 0, "availableLocations": ["emergency_department", "icu"], "displayRoute": "IV", "displayFrequency": "Once", "resultSection": "treatment" },
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{ "code": "ceftriaxone", "canonicalName": "Intravenous ceftriaxone", "category": "medication", "aliases": ["rocephin", "antibiotic"], "defaultTurnaroundMinutes": 0, "availableLocations": [], "displayRoute": "IV", "displayFrequency": "Once", "resultSection": "treatment" },
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{ "code": "serial_bmp", "canonicalName": "Basic metabolic panel every 4 hours", "category": "laboratory", "aliases": ["repeat electrolytes", "serial chemistry", "monitor potassium"], "defaultTurnaroundMinutes": 0, "availableLocations": ["emergency_department", "icu"], "displayRoute": "Blood", "displayFrequency": "Every 4 hours", "resultSection": "lab" },
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{ "code": "hourly_glucose", "canonicalName": "Capillary glucose every hour", "category": "monitoring", "aliases": ["hourly glucose", "fingerstick glucose", "poc glucose"], "defaultTurnaroundMinutes": 0, "availableLocations": ["emergency_department", "icu"], "displayRoute": "Capillary", "displayFrequency": "Every hour", "resultSection": "treatment" },
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{ "code": "icu_admission", "canonicalName": "Admit to intensive care unit", "category": "disposition", "aliases": ["icu", "intensive care admission"], "defaultTurnaroundMinutes": 0, "availableLocations": ["emergency_department"], "displayRoute": "", "displayFrequency": "Once", "resultSection": "treatment" }
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],
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"cases": [
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{
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"externalId": "ccs-endocrine-dka-emergency-001",
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"isPublished": true,
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"title": "Vomiting and progressive lethargy",
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"system": "Endocrine System",
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"presentingLocation": "emergency_department",
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"realTimeMinutes": 20,
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"difficulty": 2,
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"tags": ["diabetic ketoacidosis", "hyperglycemic crisis", "fluid resuscitation", "insulin", "potassium"],
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"initialChart": {
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"patientSummary": "24-year-old woman with type 1 diabetes mellitus",
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"reasonForEncounter": "Two days of vomiting, abdominal discomfort, and progressive lethargy after stopping insulin when oral intake declined.",
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"appearance": "She is lethargic but arousable. Mucous membranes are dry, and respirations are deep and rapid.",
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"history": "She uses basal-bolus insulin and has no known kidney disease. She reports no dysuria, cough, diarrhea, alcohol use, or pregnancy symptoms. She has taken no insulin for approximately 36 hours.",
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"historySections": [
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{ "code": "hpi", "title": "History of present illness", "text": "Two days of vomiting, abdominal discomfort, and progressive lethargy followed reduced oral intake. She stopped all insulin approximately 36 hours ago." },
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{ "code": "past_medical_history", "title": "Past medical history", "text": "Type 1 diabetes mellitus treated with a basal-bolus insulin regimen. No known kidney disease." },
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{ "code": "medications", "title": "Medications", "text": "Basal and mealtime insulin; no doses for approximately 36 hours." },
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{ "code": "allergies", "title": "Allergies", "text": "No known drug allergies." },
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{ "code": "review_of_systems", "title": "Review of systems", "text": "No dysuria, cough, diarrhea, alcohol use, or pregnancy symptoms." }
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],
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"vitals": { "temperature": "37.3 C (99.1 F)", "bloodPressure": "88/56 mm Hg", "pulse": "118/min", "respirations": "28/min", "oxygenSaturation": "98% on room air", "height": "165 cm (65 in)", "weight": "62 kg (137 lb)", "bmi": "22.8 kg/m²" },
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"simulatedStartUtc": "2026-07-15T08:00:00Z",
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"initialOrderCodes": []
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},
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"initialInterview": {
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"startNodeId": "greeting",
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"nodes": [
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{
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"id": "greeting",
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"patientText": "Doctor, I feel awful. I can barely keep my eyes open.",
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"isTerminal": false,
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"choices": [
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{ "id": "ask_chief_concern", "text": "Tell me what brought you in today.", "nextNodeId": "chief_concern" },
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{ "id": "ask_current_problem", "text": "What has been happening recently?", "nextNodeId": "chief_concern" }
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]
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},
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{
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"id": "chief_concern",
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"patientText": "I have been vomiting for two days, my stomach hurts, and I have become more and more tired.",
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"isTerminal": false,
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"choices": [
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{ "id": "ask_insulin_use", "text": "Have you been taking your insulin?", "nextNodeId": "insulin_history" },
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{ "id": "ask_diabetes_treatment", "text": "How have you managed your diabetes during this illness?", "nextNodeId": "insulin_history" }
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]
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},
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{
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"id": "insulin_history",
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"patientText": "I stopped all of my insulin about a day and a half ago because I was not eating.",
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"isTerminal": false,
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"choices": [
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{ "id": "ask_associated_symptoms", "text": "Have you noticed any other symptoms?", "nextNodeId": "associated_symptoms" },
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{ "id": "ask_infection_symptoms", "text": "Any fever, cough, urinary symptoms, or diarrhea?", "nextNodeId": "associated_symptoms" }
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]
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},
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{
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"id": "associated_symptoms",
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"patientText": "No cough, burning with urination, or diarrhea. I do not think I have had a fever.",
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"isTerminal": false,
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"choices": [
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{ "id": "ask_medical_history", "text": "Tell me about your medical history and medications.", "nextNodeId": "background" },
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{ "id": "ask_allergies", "text": "Do you have kidney problems, take other medicines, or have medication allergies?", "nextNodeId": "background" }
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]
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},
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{
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"id": "background",
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"patientText": "I have type 1 diabetes and normally use long-acting and mealtime insulin. I have no kidney disease and no known drug allergies.",
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"isTerminal": false,
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"choices": [
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{ "id": "finish_interview", "text": "Thank you. I am going to examine you and begin your evaluation.", "nextNodeId": "interview_complete" }
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]
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},
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{
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"id": "interview_complete",
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"patientText": "Okay, doctor.",
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"isTerminal": true,
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"choices": []
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}
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]
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},
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"allowedLocations": ["emergency_department", "icu", "ward"],
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"exams": [
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{ "code": "general_exam", "name": "General and hydration examination", "durationMinutes": 1, "finding": "Lethargic but arousable; dry mucous membranes, delayed capillary refill, and poor skin turgor." },
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{ "code": "cardiopulmonary_exam", "name": "Cardiopulmonary examination", "durationMinutes": 1, "finding": "Tachycardic with regular rhythm; lungs are clear. Respirations are deep without wheezing or crackles." },
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{ "code": "abdominal_exam", "name": "Abdominal examination", "durationMinutes": 1, "finding": "Mild diffuse tenderness without guarding, rebound, or focal peritoneal findings." },
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{ "code": "neurologic_exam", "name": "Neurologic examination", "durationMinutes": 1, "finding": "She opens her eyes to voice, follows simple commands, and has no focal deficit." }
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],
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"orderResponses": [
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{ "orderCode": "normal_saline_bolus", "turnaroundMinutes": 0, "result": "Isotonic crystalloid infusion is initiated.", "vitalPatches": { "bloodPressure": "104/66 mm Hg", "pulse": "102/min" } },
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{ "orderCode": "balanced_crystalloid_bolus", "turnaroundMinutes": 0, "result": "Balanced crystalloid infusion is initiated.", "vitalPatches": { "bloodPressure": "104/66 mm Hg", "pulse": "102/min" } },
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{ "orderCode": "bmp", "turnaroundMinutes": 12, "result": "Basic metabolic panel: sodium 131 mEq/L, potassium 5.3 mEq/L, chloride 91 mEq/L, bicarbonate 7 mEq/L, glucose 580 mg/dL, BUN 34 mg/dL, creatinine 1.8 mg/dL. Anion gap is 33." },
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{ "orderCode": "venous_blood_gas", "turnaroundMinutes": 8, "result": "Venous blood gas: pH 7.08, PCO2 22 mm Hg." },
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{ "orderCode": "beta_hydroxybutyrate", "turnaroundMinutes": 15, "result": "Serum beta-hydroxybutyrate is 7.8 mmol/L." },
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{ "orderCode": "cbc", "turnaroundMinutes": 12, "result": "Leukocyte count is 14,200/mm3, hemoglobin is 15.1 g/dL, and platelet count is 286,000/mm3." },
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{ "orderCode": "urinalysis", "turnaroundMinutes": 15, "result": "Urinalysis shows 4+ glucose, 3+ ketones, and no leukocyte esterase or nitrites." },
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{ "orderCode": "pregnancy_test", "turnaroundMinutes": 15, "result": "Serum beta-hCG is negative." },
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{ "orderCode": "ecg", "turnaroundMinutes": 10, "result": "ECG shows sinus tachycardia without acute ischemic changes or marked T-wave peaking." },
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{ "orderCode": "insulin_infusion", "turnaroundMinutes": 0, "result": "Regular insulin infusion is initiated." },
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{ "orderCode": "potassium_chloride_iv", "turnaroundMinutes": 0, "result": "Potassium supplementation is added to intravenous fluid." },
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{ "orderCode": "dextrose_half_normal_saline", "turnaroundMinutes": 0, "result": "Dextrose-containing intravenous fluid is initiated while insulin continues." },
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{ "orderCode": "serial_bmp", "turnaroundMinutes": 240, "result": "Repeat chemistry: sodium 136 mEq/L, potassium 4.0 mEq/L, chloride 101 mEq/L, bicarbonate 13 mEq/L, glucose 190 mg/dL. Anion gap is 22." },
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{ "orderCode": "sodium_bicarbonate_iv", "turnaroundMinutes": 0, "result": "Sodium bicarbonate is administered despite pH above the threshold for routine use." }
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],
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"events": [
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{ "id": "volume_response", "triggerMinute": 15, "requiresOrderCodes": [], "requiresAnyOrderCodes": ["normal_saline_bolus", "balanced_crystalloid_bolus"], "message": "After initial fluid resuscitation, perfusion and alertness improve.", "vitalPatches": { "bloodPressure": "108/68 mm Hg", "pulse": "98/min" }, "endCase": false },
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{ "id": "metabolic_improvement", "triggerMinute": 270, "requiresOrderCodes": ["insulin_infusion", "potassium_chloride_iv", "dextrose_half_normal_saline", "serial_bmp"], "message": "Glucose and acidosis continue to improve without hypoglycemia or hypokalemia. Case-end instructions are available.", "vitalPatches": { "bloodPressure": "112/70 mm Hg", "pulse": "88/min", "respirations": "18/min" }, "endCase": true }
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],
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"scoringCriteria": [
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{ "id": "assess_hydration", "title": "Assess hydration and mental status", "actionType": "exam", "targetCode": "general_exam", "points": 4, "latestMinute": 10, "afterTargetCode": "", "rationale": "Early assessment should identify severe volume depletion and altered mentation." },
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{ "id": "iv_access", "title": "Establish intravenous access", "actionType": "order", "targetCode": "iv_access", "points": 4, "latestMinute": 5, "afterTargetCode": "", "rationale": "Prompt intravenous access is needed for fluid resuscitation and treatment." },
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{ "id": "cardiac_monitor", "title": "Start cardiac monitoring", "actionType": "order", "targetCode": "cardiac_monitor", "points": 3, "latestMinute": 10, "afterTargetCode": "", "rationale": "Potassium shifts during DKA treatment create arrhythmia risk." },
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{ "id": "fluid_resuscitation", "title": "Begin isotonic fluid resuscitation", "actionType": "order", "targetCode": "", "targetCodes": ["normal_saline_bolus", "balanced_crystalloid_bolus"], "points": 12, "latestMinute": 10, "afterTargetCode": "", "rationale": "Immediate isotonic crystalloid treats severe intravascular depletion and hypotension." },
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{ "id": "electrolytes", "title": "Check electrolytes and anion gap", "actionType": "order", "targetCode": "bmp", "points": 8, "latestMinute": 10, "afterTargetCode": "", "rationale": "Electrolytes, renal function, glucose, bicarbonate, and anion gap guide diagnosis and safe treatment." },
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{ "id": "ketone_confirmation", "title": "Measure serum beta-hydroxybutyrate", "actionType": "order", "targetCode": "beta_hydroxybutyrate", "points": 5, "latestMinute": 20, "afterTargetCode": "", "rationale": "Direct beta-hydroxybutyrate measurement confirms and monitors clinically important ketonemia." },
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{ "id": "acid_base", "title": "Assess acid-base status", "actionType": "order", "targetCode": "venous_blood_gas", "points": 5, "latestMinute": 20, "afterTargetCode": "", "rationale": "Venous pH establishes the severity of metabolic acidosis without requiring an arterial sample." },
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{ "id": "pregnancy", "title": "Check pregnancy status", "actionType": "order", "targetCode": "pregnancy_test", "points": 3, "latestMinute": 30, "afterTargetCode": "", "rationale": "Pregnancy status affects the differential diagnosis, monitoring, and disposition in a reproductive-age patient." },
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{ "id": "insulin_after_potassium", "title": "Start insulin after assessing potassium", "actionType": "order", "targetCode": "insulin_infusion", "points": 15, "latestMinute": 30, "afterTargetCode": "bmp", "rationale": "Insulin suppresses ketogenesis but should follow assessment of serum potassium." },
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{ "id": "hourly_glucose", "title": "Monitor glucose hourly", "actionType": "order", "targetCode": "hourly_glucose", "points": 5, "latestMinute": 35, "afterTargetCode": "insulin_infusion", "rationale": "Frequent glucose monitoring is required during continuous insulin therapy." },
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{ "id": "serial_electrolytes", "title": "Monitor serial electrolytes", "actionType": "order", "targetCode": "serial_bmp", "points": 8, "latestMinute": 40, "afterTargetCode": "insulin_infusion", "rationale": "Serial chemistry identifies falling potassium and tracks resolution of acidosis." },
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{ "id": "potassium_replacement", "title": "Replace potassium during treatment", "actionType": "order", "targetCode": "potassium_chloride_iv", "points": 10, "earliestMinute": 12, "latestMinute": 260, "afterTargetCode": "bmp", "rationale": "Total-body potassium is depleted and replacement is needed as serum potassium falls during therapy." },
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{ "id": "dextrose_with_continued_insulin", "title": "Add dextrose while continuing insulin", "actionType": "order", "targetCode": "dextrose_half_normal_saline", "points": 10, "earliestMinute": 240, "latestMinute": 300, "afterTargetCode": "insulin_infusion", "rationale": "When glucose approaches 200 mg/dL before ketoacidosis resolves, add dextrose so insulin can continue safely." },
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{ "id": "icu_disposition", "title": "Admit for intensive monitoring", "actionType": "order", "targetCode": "icu_admission", "points": 8, "latestMinute": 60, "afterTargetCode": "", "rationale": "Severe DKA with hypotension and altered mentation requires closely monitored inpatient care." },
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{ "id": "avoid_bicarbonate", "title": "Avoid unnecessary bicarbonate", "actionType": "order", "targetCode": "sodium_bicarbonate_iv", "points": -10, "afterTargetCode": "", "rationale": "Routine bicarbonate provides no benefit at pH 7.08 and may worsen potassium shifts and other complications." },
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{ "id": "avoid_empiric_antibiotic", "title": "Avoid unsupported empiric antibiotics", "actionType": "order", "targetCode": "ceftriaxone", "points": -4, "afterTargetCode": "", "rationale": "No history, examination, or urine findings support bacterial infection requiring empiric ceftriaxone." }
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],
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"references": [
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{ "title": "Hyperglycemic Crises in Adults With Diabetes: A Consensus Report", "publisher": "American Diabetes Association, EASD, AACE, JBDS-IP, and Diabetes Technology Society", "url": "https://diabetesjournals.org/care/article/47/8/1257/156808/Hyperglycemic-Crises-in-Adults-With-Diabetes-A", "supports": "DKA diagnosis, fluid resuscitation, insulin and potassium sequencing, dextrose addition, monitoring, bicarbonate avoidance, and resolution criteria", "accessedOn": "2026-07-15", "reviewer": "Question bank editorial review" },
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{ "title": "Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026", "publisher": "American Diabetes Association", "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC12690178/", "supports": "Current hyperglycemic-crisis recognition, management, monitoring, and prevention recommendations", "accessedOn": "2026-07-15", "reviewer": "Question bank editorial review" }
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]
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}
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],
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"validateOnly": false
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}
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