{
  "scenario": {
    "id": "dka-electrolyte-01",
    "name": "Diabetic Ketoacidosis with Electrolyte Derangement",
    "description": "34-year-old male presenting with Kussmaul breathing, tachycardia, and dehydration. Glucose >400 on arrival with hyperkalemia (5.6 mEq/L) due to acidosis. During insulin/fluid resuscitation, potassium drops critically low (3.0 mEq/L) requiring KCl replacement. Demonstrates V-shaped potassium curve and gradual normalization over 5 hours.",
    "durationMinutes": 300,
    "tags": [
      "dka",
      "diabetes",
      "electrolyte",
      "potassium",
      "hyperglycemia",
      "emergency",
      "insulin",
      "kussmaul",
      "acidosis"
    ]
  },
  "patient": {
    "firstName": "Marcus",
    "lastName": "Devlin",
    "dateOfBirth": "1992-04-17",
    "gender": "Male"
  },
  "encounter": {
    "department": "Emergency",
    "encounterType": "Emergency",
    "attendingPhysician": "Dr. Priya Nair",
    "roomBed": "ED-07B",
    "admissionReason": "Altered mental status, rapid deep breathing, severe dehydration, blood glucose >400 mg/dL"
  },
  "events": [
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 112,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Arrival \u2014 Kussmaul breathing, tachycardia, dry mucous membranes. NEWS2: HR=2, RR=3, SBP=1, Temp=0, SpO2=0, AVPU=0. Total=6, RR single=3 -> EMERGENCY"
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 28,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 102,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 58,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.2,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 97,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 2,
      "type": "observation",
      "data": {
        "code": "GLUCOSE_MG_DL",
        "value": 438,
        "unit": "mg/dL",
        "source": "Lab"
      },
      "note": "Initial labs \u2014 critically elevated glucose, hyperkalemia from acidotic K+ shift, elevated lactate"
    },
    {
      "offsetMinutes": 2,
      "type": "observation",
      "data": {
        "code": "POTASSIUM_MEQ_L",
        "value": 5.6,
        "unit": "mEq/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 2,
      "type": "observation",
      "data": {
        "code": "LACTATE_MMOL_L",
        "value": 2.4,
        "unit": "mmol/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "order",
      "data": {
        "orderType": "Lab",
        "description": "Basic metabolic panel, stat",
        "orderedBy": "Dr. Priya Nair"
      }
    },
    {
      "offsetMinutes": 2,
      "type": "order_result",
      "data": {
        "orderDescription": "Basic metabolic panel, stat",
        "resultSummary": "Glucose 438 mg/dL (critical high), K+ 5.6 mEq/L (critical high), CO2 12 mEq/L (low), anion gap 28 (elevated), BUN 32 mg/dL (elevated), Cr 1.4 mg/dL \u2014 consistent with DKA"
      },
      "note": "BMP confirms DKA: high anion gap metabolic acidosis with hyperglycemia"
    },
    {
      "offsetMinutes": 0,
      "type": "order",
      "data": {
        "orderType": "Lab",
        "description": "Venous blood gas, stat",
        "orderedBy": "Dr. Priya Nair"
      }
    },
    {
      "offsetMinutes": 3,
      "type": "order_result",
      "data": {
        "orderDescription": "Venous blood gas, stat",
        "resultSummary": "pH 7.18 (low), pCO2 22 mmHg (compensatory respiratory alkalosis), HCO3 10 mEq/L (critically low) \u2014 severe metabolic acidosis"
      },
      "note": "VBG confirms severe acidosis driving Kussmaul breathing"
    },
    {
      "offsetMinutes": 0,
      "type": "order",
      "data": {
        "orderType": "Lab",
        "description": "Urinalysis, stat",
        "orderedBy": "Dr. Priya Nair"
      }
    },
    {
      "offsetMinutes": 4,
      "type": "order_result",
      "data": {
        "orderDescription": "Urinalysis, stat",
        "resultSummary": "Ketones 3+ (large), glucose 4+ (>1000 mg/dL), specific gravity 1.035 (concentrated) \u2014 confirms ketonuria and dehydration"
      }
    },
    {
      "offsetMinutes": 5,
      "type": "medication",
      "data": {
        "drugName": "sodium chloride 0.9% (Normal Saline)",
        "dose": 1000,
        "doseUnit": "mL",
        "route": "IV",
        "administeredBy": "nurse-rn-4"
      },
      "note": "NS 1L bolus started for volume resuscitation"
    },
    {
      "offsetMinutes": 15,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 115,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Worsening slightly before treatment effect. NS bolus running. NEWS2: HR=2, RR=3, SBP=2, Temp=0, SpO2=0, AVPU=0. Total=7, RR single=3 -> EMERGENCY"
    },
    {
      "offsetMinutes": 15,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 29,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 15,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 100,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 15,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 56,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 15,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.1,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 15,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 97,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 15,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 30,
      "type": "medication",
      "data": {
        "drugName": "regular insulin",
        "dose": 0.1,
        "doseUnit": "units/kg/hr",
        "route": "IV",
        "administeredBy": "nurse-rn-4"
      },
      "note": "Insulin drip started at 0.1 units/kg/hr after first liter NS \u2014 will drive K+ intracellularly"
    },
    {
      "offsetMinutes": 30,
      "type": "medication",
      "data": {
        "drugName": "sodium chloride 0.9% (Normal Saline)",
        "dose": 500,
        "doseUnit": "mL/hr",
        "route": "IV",
        "administeredBy": "nurse-rn-4"
      },
      "note": "NS continued at 500 mL/hr for ongoing volume resuscitation"
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 118,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Peak worsening \u2014 insulin drip just started. NEWS2: HR=2, RR=3, SBP=2, Temp=0, SpO2=0, AVPU=0. Total=7, RR single=3 -> EMERGENCY"
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 30,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 98,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 55,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.2,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 96,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 116,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Insulin/fluids running 15 min. Slight HR improvement. NEWS2: HR=2, RR=3, SBP=2, Temp=0, SpO2=0, AVPU=0. Total=7, RR single=3 -> EMERGENCY"
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 28,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 100,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 57,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.1,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 97,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 114,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Glucose dropping, K+ declining as insulin drives it intracellular. NEWS2: HR=2, RR=3, SBP=1, Temp=0, SpO2=0, AVPU=0. Total=6, RR single=3 -> EMERGENCY"
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 27,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 102,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 59,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.1,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 97,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 62,
      "type": "observation",
      "data": {
        "code": "GLUCOSE_MG_DL",
        "value": 380,
        "unit": "mg/dL",
        "source": "Lab"
      },
      "note": "1-hour labs \u2014 glucose dropping nicely, K+ falling as insulin shifts it intracellularly (dangerous trend)"
    },
    {
      "offsetMinutes": 62,
      "type": "observation",
      "data": {
        "code": "POTASSIUM_MEQ_L",
        "value": 4.8,
        "unit": "mEq/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 62,
      "type": "observation",
      "data": {
        "code": "LACTATE_MMOL_L",
        "value": 2.1,
        "unit": "mmol/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 57,
      "type": "order",
      "data": {
        "orderType": "Lab",
        "description": "Basic metabolic panel, repeat",
        "orderedBy": "Dr. Priya Nair"
      }
    },
    {
      "offsetMinutes": 62,
      "type": "order_result",
      "data": {
        "orderDescription": "Basic metabolic panel, repeat",
        "resultSummary": "Glucose 380 mg/dL (critical high, down from 438), K+ 4.8 mEq/L (down from 5.6, now normal range), CO2 14 mEq/L (improving), anion gap 24 (still elevated)"
      },
      "note": "K+ dropping from 5.6 to 4.8 in 1 hour \u2014 rate suggests will fall below 3.5 within 2 hours, anticipate replacement need"
    },
    {
      "offsetMinutes": 75,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 112,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Gradual improvement with fluids. NEWS2: HR=2, RR=3, SBP=1, Temp=0, SpO2=0, AVPU=0. Total=6, RR single=3 -> EMERGENCY"
    },
    {
      "offsetMinutes": 75,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 26,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 75,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 104,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 75,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 60,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 75,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 75,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 97,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 75,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 110,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "HR drops out of critical range. RR still critical. NEWS2: HR=1, RR=3, SBP=1, Temp=0, SpO2=0, AVPU=0. Total=5, RR single=3 -> EMERGENCY"
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 25,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 106,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 62,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 97,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 105,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 108,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Improving \u2014 RR drops below 25. NEWS2: HR=1, RR=2, SBP=1, Temp=0, SpO2=0, AVPU=0. Total=4. No longer EMERGENCY by total or single param."
    },
    {
      "offsetMinutes": 105,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 24,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 105,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 108,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 105,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 64,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 105,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 105,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 97,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 105,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 105,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "NEWS2: HR=1, RR=2, SBP=1, Temp=0, SpO2=0, AVPU=0. Total=4. K+ critically low on labs!"
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 23,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 108,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 65,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 97,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 122,
      "type": "observation",
      "data": {
        "code": "GLUCOSE_MG_DL",
        "value": 245,
        "unit": "mg/dL",
        "source": "Lab"
      },
      "note": "2-hour labs \u2014 glucose improving but K+ critically low at 3.2, nadir of V-curve. Cardiac risk from hypokalemia."
    },
    {
      "offsetMinutes": 122,
      "type": "observation",
      "data": {
        "code": "POTASSIUM_MEQ_L",
        "value": 3.2,
        "unit": "mEq/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 122,
      "type": "observation",
      "data": {
        "code": "LACTATE_MMOL_L",
        "value": 1.6,
        "unit": "mmol/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 122,
      "type": "order_result",
      "data": {
        "orderDescription": "Basic metabolic panel, repeat",
        "resultSummary": "Glucose 245 mg/dL (critical high, improving), K+ 3.2 mEq/L (WARNING \u2014 dropped from 4.8, insulin-driven intracellular shift), CO2 17 mEq/L (improving), anion gap 18 (closing)"
      },
      "note": "CRITICAL: K+ 3.2 \u2014 below 3.5, risk of cardiac arrhythmia. Must start KCl replacement before K+ drops further."
    },
    {
      "offsetMinutes": 118,
      "type": "order",
      "data": {
        "orderType": "Imaging",
        "description": "12-Lead ECG, stat",
        "orderedBy": "Dr. Priya Nair"
      }
    },
    {
      "offsetMinutes": 123,
      "type": "order_result",
      "data": {
        "orderDescription": "12-Lead ECG, stat",
        "resultSummary": "Sinus tachycardia at 105 bpm, ST depression in V3-V4, prominent U waves in V2-V4, flattened T waves \u2014 changes consistent with hypokalemia"
      },
      "note": "ECG changes confirm electrophysiologic effects of hypokalemia"
    },
    {
      "offsetMinutes": 135,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 103,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "NEWS2: HR=1, RR=2, SBP=1, Temp=0, SpO2=0, AVPU=0. Total=4. Awaiting K+ replacement order."
    },
    {
      "offsetMinutes": 135,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 22,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 135,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 110,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 135,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 66,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 135,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 135,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 97,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 135,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "medication",
      "data": {
        "drugName": "potassium chloride (KCl)",
        "dose": 40,
        "doseUnit": "mEq",
        "route": "IV",
        "administeredBy": "nurse-rn-4"
      },
      "note": "KCl 40 mEq IV over 4 hours started for critical hypokalemia (K+ 3.2). Max rate 10 mEq/hr via peripheral line."
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 100,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "K+ replacement started. NEWS2: HR=1, RR=2, SBP=0, Temp=0, SpO2=0, AVPU=0. Total=3."
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 22,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 112,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 68,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 97,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 170,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 98,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Steady improvement. Glucose still dropping, K+ being replaced. NEWS2: HR=1, RR=2, SBP=0, Temp=0, SpO2=0, AVPU=0. Total=3."
    },
    {
      "offsetMinutes": 170,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 21,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 170,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 114,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 170,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 70,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 170,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 170,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 98,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 170,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 182,
      "type": "observation",
      "data": {
        "code": "GLUCOSE_MG_DL",
        "value": 168,
        "unit": "mg/dL",
        "source": "Lab"
      },
      "note": "3-hour labs \u2014 glucose near warning range, K+ recovering with replacement, lactate normalizing"
    },
    {
      "offsetMinutes": 182,
      "type": "observation",
      "data": {
        "code": "POTASSIUM_MEQ_L",
        "value": 3.6,
        "unit": "mEq/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 182,
      "type": "observation",
      "data": {
        "code": "LACTATE_MMOL_L",
        "value": 1.2,
        "unit": "mmol/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 182,
      "type": "order_result",
      "data": {
        "orderDescription": "Basic metabolic panel, repeat",
        "resultSummary": "Glucose 168 mg/dL (warning range, improving), K+ 3.6 mEq/L (recovering with replacement, now normal), CO2 20 mEq/L (normalizing), anion gap 14 (closed)"
      },
      "note": "Anion gap closed \u2014 DKA resolving. K+ responding to replacement. Consider switching to D5 1/2NS when glucose <200."
    },
    {
      "offsetMinutes": 185,
      "type": "medication",
      "data": {
        "drugName": "dextrose 5% in 0.45% sodium chloride (D5 1/2NS)",
        "dose": 250,
        "doseUnit": "mL/hr",
        "route": "IV",
        "administeredBy": "nurse-rn-4"
      },
      "note": "Switched to D5 1/2NS as glucose approaching 200 mg/dL \u2014 prevents hypoglycemia while continuing insulin drip"
    },
    {
      "offsetMinutes": 190,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 95,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Continued improvement. NEWS2: HR=1, RR=0, SBP=0, Temp=0, SpO2=0, AVPU=0. Total=1."
    },
    {
      "offsetMinutes": 190,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 20,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 190,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 116,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 190,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 72,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 190,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 190,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 98,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 190,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 93,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Nearly normal vitals. NEWS2: HR=1, RR=0, SBP=0, Temp=0, SpO2=0, AVPU=0. Total=1."
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 19,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 118,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 74,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 98,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 90,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Near baseline. NEWS2: HR=0, RR=0, SBP=0, Temp=0, SpO2=0, AVPU=0. Total=0."
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 18,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 120,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 76,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 36.9,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 98,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 270,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 88,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Final vital cluster. NEWS2: HR=0, RR=0, SBP=0, Temp=0, SpO2=0, AVPU=0. Total=0."
    },
    {
      "offsetMinutes": 270,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 17,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 270,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 122,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 270,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 78,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 270,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 270,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 98,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 270,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 272,
      "type": "observation",
      "data": {
        "code": "GLUCOSE_MG_DL",
        "value": 124,
        "unit": "mg/dL",
        "source": "Lab"
      },
      "note": "Final labs \u2014 glucose normal, K+ recovered to normal, lactate normal. DKA resolved."
    },
    {
      "offsetMinutes": 272,
      "type": "observation",
      "data": {
        "code": "POTASSIUM_MEQ_L",
        "value": 4.1,
        "unit": "mEq/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 272,
      "type": "observation",
      "data": {
        "code": "LACTATE_MMOL_L",
        "value": 0.9,
        "unit": "mmol/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 272,
      "type": "order_result",
      "data": {
        "orderDescription": "Basic metabolic panel, repeat",
        "resultSummary": "Glucose 124 mg/dL (normal), K+ 4.1 mEq/L (normal), CO2 22 mEq/L (normal), anion gap 10 (normal), BUN 18 mg/dL, Cr 1.1 mg/dL \u2014 DKA fully resolved"
      },
      "note": "DKA resolved: anion gap closed, bicarbonate normalized, glucose normal. Plan to transition to subcutaneous insulin."
    },
    {
      "offsetMinutes": 268,
      "type": "order",
      "data": {
        "orderType": "Lab",
        "description": "Venous blood gas, repeat",
        "orderedBy": "Dr. Priya Nair"
      }
    },
    {
      "offsetMinutes": 273,
      "type": "order_result",
      "data": {
        "orderDescription": "Venous blood gas, repeat",
        "resultSummary": "pH 7.38 (normal), pCO2 38 mmHg (normal), HCO3 22 mEq/L (normal) \u2014 acidosis fully corrected"
      },
      "note": "VBG normalized \u2014 supports transition from insulin drip to subcutaneous regimen"
    },
    {
      "offsetMinutes": 300,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 86,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "End of scenario \u2014 fully resolved. NEWS2: HR=0, RR=0, SBP=0, Temp=0, SpO2=0, AVPU=0. Total=0. Patient stable for step-down."
    },
    {
      "offsetMinutes": 300,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 16,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 300,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 124,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 300,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 78,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 300,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 300,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 98,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 300,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    }
  ],
  "expectedOutcomes": [
    {
      "afterOffsetMinutes": 0,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 6,
      "description": "NEWS2=6 on arrival (HR=2, RR=3, SBP=1). RR single param=3 triggers EMERGENCY despite total only 6."
    },
    {
      "afterOffsetMinutes": 0,
      "type": "alert",
      "alertType": "NEWS2_EMERGENCY",
      "description": "NEWS2_EMERGENCY on arrival \u2014 RR 28 scores 3 (single parameter >=3 triggers emergency regardless of total)"
    },
    {
      "afterOffsetMinutes": 2,
      "type": "alert",
      "alertType": "CRITICAL_GLUCOSE",
      "description": "Glucose 438 mg/dL \u2014 critically elevated (>180 mg/dL), consistent with DKA presentation"
    },
    {
      "afterOffsetMinutes": 2,
      "type": "alert",
      "alertType": "CRITICAL_POTASSIUM_HIGH",
      "description": "Potassium 5.6 mEq/L \u2014 critically high (>5.5), caused by acidotic extracellular K+ shift in DKA"
    },
    {
      "afterOffsetMinutes": 2,
      "type": "alert",
      "alertType": "CRITICAL_LACTATE",
      "description": "Lactate 2.4 mmol/L \u2014 critically elevated (>2.0), indicating tissue hypoperfusion"
    },
    {
      "afterOffsetMinutes": 30,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 7,
      "description": "NEWS2 peaks at 7 (HR=2, RR=3, SBP=2) at T+30 when vitals are worst before treatment effect. RR single=3 -> EMERGENCY."
    },
    {
      "afterOffsetMinutes": 62,
      "type": "alert",
      "alertType": "CRITICAL_GLUCOSE",
      "description": "Glucose 380 mg/dL \u2014 still critically high but trending down from 438. Insulin drip effect visible."
    },
    {
      "afterOffsetMinutes": 90,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 5,
      "description": "NEWS2=5 at T+90 (HR=1, RR=3, SBP=1). Still EMERGENCY due to RR single=3 but total score improving."
    },
    {
      "afterOffsetMinutes": 105,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 4,
      "description": "NEWS2 drops to 4 (HR=1, RR=2, SBP=1) \u2014 RR finally below 25, no more single param=3. No longer EMERGENCY."
    },
    {
      "afterOffsetMinutes": 122,
      "type": "alert",
      "alertType": "CRITICAL_POTASSIUM_LOW",
      "description": "Potassium 3.2 mEq/L \u2014 WARNING range (3.0-3.4). Dangerous drop from 5.6 to 3.2 during insulin treatment as K+ shifts intracellularly. ECG shows hypokalemic changes."
    },
    {
      "afterOffsetMinutes": 122,
      "type": "alert",
      "alertType": "CRITICAL_GLUCOSE",
      "description": "Glucose 245 mg/dL \u2014 still critically high (>180) but steadily improving from 438 to 245 over 2 hours"
    },
    {
      "afterOffsetMinutes": 150,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 3,
      "description": "NEWS2=3 at T+150 (HR=1, RR=2). Improving \u2014 KCl replacement started."
    },
    {
      "afterOffsetMinutes": 182,
      "type": "alert",
      "alertType": "WARNING_POTASSIUM",
      "description": "Potassium 3.6 mEq/L \u2014 recovered to normal range (3.5-5.0) with KCl replacement"
    },
    {
      "afterOffsetMinutes": 190,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 1,
      "description": "NEWS2=1 at T+190 (HR=1 only). Near-normal vitals as DKA resolves."
    },
    {
      "afterOffsetMinutes": 240,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 0,
      "description": "NEWS2=0 at T+240. All vitals normalized \u2014 HR 90, RR 18, SBP 120, SpO2 98."
    },
    {
      "afterOffsetMinutes": 272,
      "type": "alert",
      "alertType": "NORMAL_GLUCOSE",
      "description": "Glucose 124 mg/dL \u2014 normalized (70-140 range). DKA fully resolved."
    },
    {
      "afterOffsetMinutes": 272,
      "type": "alert",
      "alertType": "NORMAL_POTASSIUM",
      "description": "Potassium 4.1 mEq/L \u2014 fully normalized. V-curve complete: 5.6 (high) -> 3.2 (critical low) -> 4.1 (normal)."
    }
  ]
}