Abnormal narrative bank — focused / at-risk
Six focused abnormal narratives carrying the full necessity chain — finding, severity, comparison, risk, action, notification, and reassessment.
A1 Severe hypoglycemia with altered mentation | Skilled assessment finding a blood glucose of 41 mg/dL with confusion and diaphoresis — severe hypoglycemia and a change from the patient’s usual range. Glucagon was administered per order because the patient could not safely take oral carbohydrate; glucose was rechecked at 96 mg/dL but mentation remained slow, so EMS was activated. The provider was notified at 09:25; the sick-day and rescue plan was reinforced once the patient stabilized, and the regimen flagged for review to identify and correct the cause of the low (cross-reference Diabetes overlay). |
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A2 Diabetic ketoacidosis / hyperosmolar state | Skilled assessment of a patient with blood glucose over 450 mg/dL, dry mucous membranes and poor skin turgor, deep rapid respirations with a fruity odor, and new lethargy — findings concerning for diabetic ketoacidosis or a hyperosmolar hyperglycemic state. EMS was activated for emergent evaluation; the provider was notified at 13:40. Hydration status and mental status were monitored pending transport, no further insulin was given outside orders, and the precipitating factors (illness, missed insulin) were documented to inform the plan (cross-reference Diabetes overlay). |
A3 Adrenal crisis | Skilled assessment of a steroid-dependent patient with hypotension, profound weakness, nausea, and new confusion after missing several steroid doses during an illness — findings concerning for adrenal crisis. Hydrocortisone was administered per the patient’s emergency order and EMS activated; the provider was notified at 11:05. Vital signs and mental status were monitored pending transport, and the never-stop-abruptly and stress-dose rules were reinforced once the patient stabilized to prevent recurrence. |
A4 Regimen no longer controlling glucose | Skilled assessment with a glucose log showing values of 250–340 mg/dL over four days, persistently above the patient’s individualized target, without intercurrent illness — a pattern indicating the current regimen is no longer controlling glucose and raising the risk of decompensation and complications. The provider was notified at 10:30 with the pattern; orders to adjust the insulin regimen were received and taught. Monitoring frequency was increased and the pattern will be reassessed next visit to confirm the adjustment brings glucose toward target (cross-reference Diabetes overlay). |
A5 New foot lesion with neuropathy | Skilled assessment identifying a new 1 cm painless plantar ulcer that the patient had not noticed, with absent protective sensation at the site — new and high-risk for limb loss in a neuropathic foot. The area was offloaded and the provider notified at 14:15; orders for wound care and podiatry were received. Urgent foot-care teaching was provided and the limb-threatening nature of a painless wound in an insensate foot emphasized; the wound and sensation will be reassessed next visit (cross-reference Wounds and Touch/Sensation, Diabetes overlay). |
A6 Thyroid emergency | Skilled assessment of a hyperthyroid patient with a temperature of 103°F, a rapid irregular pulse near 140, marked agitation, and new confusion — findings concerning for thyroid storm. Vital signs were obtained and EMS activated for emergent evaluation; the provider was notified at 15:20. Cardiac and mental status were monitored pending transport, and the precipitating factors documented; the systemic thyroid picture and the neck exam are detailed in Neck/Thyroid (cross-reference Cardiovascular for the rapid atrial fibrillation). |