text: HISTORY OF PRESENT ILLNESS  Date of birth  10  4  88 . This patient is a 5 year old white female with a history of type I renal tubular acidosis on nephrocalcinosis who was admitted to Noughwell Entanbon Health of Washington on 9  5  93 at 2116 hours with a 2-3 day history of chills   fevers   cough   vomiting and weakness  unable to walk  . At Noughwell Entanbon Health   her temperature was 101   pulse 135   blood pressure 94  74   respiratory rate 20 . Positive findings of physical examination include chicken pox lesions on thorax   sunken eyes   thick nasal discharge   dry lips   tongue and mucous membranes   red tonsils . The remainder of the physical examination was considered within normal limits . Admission diagnosis at Ni Hospital &aposs  vomiting and dehydration   hypokalemia   hyponatremia   tonsillitis . A peripheral intravenous line was started on Labor Day in the a.m. No respiratory distress was noted . Oral cyanosis and shallow respirations were noted on 9  7  93 at 245 a.m. Therefore the patient was intubated at 345 a.m. on 9  7  93 . Chest x-ray was unremarkable . Cardiovascular stable   significant hypertension was noted on 9  7  93 at 510 a.m. and therefore 10 cc&aposs per kilo albumin was given . The patient was admitted was started on clear fluids   tolerated   with D5 normal saline plus 40 mEq per liter of KCL at a rate of 50 cc &aposs per hour for 9 hours .  100 cc&aposs per kilo  . Sodium and potassium at this time were 128  1.5 . At Labor Day   930 a.m.   the fluids were increased to 100 cc&aposs per hour  200 cc&aposs per kilo for 5 hours  . Electrolytes at this point were sodium 132   potassium 1.8 . At 9  6  93   230 p.m.   fluids were decreased to 75 cc&aposs per hour   150 cc&aposs per kilo   40 mEq of K phosphate added to the intravenous fluids . Electrolytes at this point were a sodium of 143 and potassium 1.7 . On 9  6  93   2200   fluids were changed to D5 normal saline plus 40 KCL and 40 K phosphate at 75 cc &aposs per hour . This rate was maintained for 11 hours . Electrolytes at this time were a sodium of 148   potassium 1.7 . At 9  7  93   100 a.m.   intravenous fluids rate was decreased to 50 cc&aposs per hour   total fluids given during the first 24 hours were 140 to 150 cc&aposs per kilo per day . At this time   sodium was 147   potassium 2.6   total sodium given during the first 24 hours 20 mEq per kilo per day . On 9  7  93 at 400 a.m.   albumin bolus 5 10 cc&aposs per kilo was given   a total of 120 cc&aposs   electrolytes were sodium 155   potassium 3.1 . At 9  7  93 at 500 a.m.   sodium bicarbonate given 60 mEq   calcium bolus 10 cc&aposs given . On 9  7   530 a.m.   D5 quarter normal saline   and 40 of K phosphate at 100 cc&aposs per hour was given . The patient was taking PO initially until 9  6  93 at 1745 . There were no abnormal findings in abdominal exam . On 9  5  93   hematocrit 48   white blood count 11.2   neutrophiles 67   bands 14   lymphs 11   monos 6   meta 2   platelets 220 000 . Copious urine output   BUN 1.0   creatinine .8 . Normal neurologic exam on admission   then lethargic on 9  6  93 at 1745   then patient became unresponsive   areflexic and limp at 9  6  93   at 1745 to 2200 . Patient was having seizures   twitching of face and rapid movements of eyes . Pupils dilated and sluggish . Valium was given at 9  7  93   0002 . IV ampicillin   chloramphenicol   ceftriaxone   and culture were sent . Finally   Fairm of Ijordcompmac Hospital transport team was called and transport team arrived on 9  7  93   630 a.m.   and on arrival patient was seizing with rhythmic eye movement to left . The patient was unresponsive   poor perfusion . Temperature was 101.8 . A second intravenous was started and given normal saline bolus   change in intravenous fluids to D5 water with 80 mEq of bicarbonate   plus 40 mEq of KCL at 45 cc&aposs per hour   bicarbonate given 2 mEq per kilo   attempted to start dopa for poor perfusion but worsening perfusion . Therefore   dopa was stopped . Total volume given as bolus 50 cc&aposs per kilo   sodium bicarbonate at 2 mEq per kilo was given . Last ABG there was 6.98   31   171   bicarbonate of 7 . Phenobarbital and Dilantin given for seizure control . Electrolytes before departure for Fairm of Ijordcompmac Hospital was a sodium of 176   potassium 2.5   chloride 140   bicarbonate 14   calcium 7.2   magnesium 2.7 . Admission to the Pediatric Intensive Care Unit at Fairm of Ijordcompmac Hospital was 9  7  93   1115 a.m. Lines placed were a right femoral triple lumen   endotracheal tube 4.0   arterial line   right radial line   Foley placed   peripheral intravenous line   nasogastric tube . On admission to Fairm of Ijordcompmac Hospital   temperature 100.2   pulse 149   respiratory rate 50   blood pressure 98  66   mean arterial pressure of 73   weight 12 kilos .