🏥Oak Valley Regional Medical Centre
Emergency Department - Clinical Decision Support
07:38 PM
MRNMRN-2026-0847291
Margaret Chen(72F)
Blood TypeA+
⚠️ALLERGIES: Penicillin (anaphylaxis); Sulfonamides (rash)
CTAS 2 - EmergentEmergency Department - Bay 7
Attending: Dr. Sarah OkaforNurse: RN James WhitfieldArrived: 14:23
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Vitals

14:31
Temperature
38.9°C🔴
Heart Rate
112bpm🔴
Blood Pressure
88/52mmHg🔴
Respiratory Rate
24/min🔴
SpO₂
91%🔴
GCS
13🟡
MAP
64mmHg🔴
Pain Scale: Unable to assess - altered LOC

Laboratory Results

14:45
WBC
18.2×10⁹/LHIGH
Lactate
4.1mmol/LHIGH
Creatinine
1.8mg/dLHIGH
Procalcitonin
2.4ng/mLHIGH
Platelets
98×10⁹/LLOW
INR
1.4HIGH
Bilirubin
2.1mg/dLHIGH
Glucose
186mg/dLHIGH
Blood Cultures:Pending (drawn at 14:35)
Urinalysis:Positive for leukocyte esterase, nitrites
CXR:Right lower lobe infiltrate - possible aspiration vs. pneumonia

SOFA Score

10
Total Score
High Risk
Respiration2
Coagulation1
Liver1
Cardiovascular3
CNS1
Renal2

Conditions

  • Type 2 Diabetes Mellitus (A1c 7.8%)
  • Hypertension
  • Chronic Kidney Disease Stage 3a
  • Atrial Fibrillation (on Apixaban)
  • Previous UTI (3 months ago - E. coli, ciprofloxacin-resistant)

Current Medications

  • Metformin 1000mg BID
  • Apixaban 5mg BID
  • Lisinopril 20mg daily
  • Metoprolol 50mg BID
  • Atorvastatin 40mg daily

Social History

Lives alone, independent ADLs, former smoker (quit 2015, 20 pack-years), no alcohol, retired teacher

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