Several readers nailed this one – valproic acid (Depakote). Valproic acid does cause hyperammonemia
This syndrome can occur with overdoses, but can also occur on apparently stable dosing.
The puzzling overdose
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But what about that impossible ABG?
I assume you are talking about the oxygen level. Perhaps the ABG was not really on room air.
only possible explanation with given info.
Did your residents pick up on that?
It speaks to the whole concept of A-a gradient, a crucial concept in taking care of sick people.