Extended criteria (experimental). This is the broader ten-condition engine, kept as a secondary area. It shows ICD-10-CM codes and illustrative grouping effects for CDI staff. The primary surface is Before you sign (kidney, measurement only). All extended pages.

ENC-00004: Luca Abernath

83F · MRN29573051 · Hospital Medicine · admitted Thu Oct 29, 2026 12:49 PM · discharged Thu Nov 05, 2026 12:42 PM · attending Dr. Cyrus Ellingham · 161 cm, 62.0 kg

Documented diagnoses (current)

Principal: “sepsis” · A41.9 Sepsis, unspecified organism
“urinary tract infection” · N39.0 Urinary tract infection, site not specified
“diastolic heart failure” · I50.30 Unspecified diastolic (congestive) heart failure
“hypertension” · I10 Essential (primary) hypertension
“hyperlipidemia” · E78.5 Hyperlipidemia, unspecified

Illustrative grouping now: MS-DRG 872 Septicemia or severe sepsis without MV >96 hours without MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 689.

Queries and events

No queries yet.

All rules applied

Rule Criteria Finding Outcome

Acute kidney injury

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule aki v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: meets_definition	`creat_ratio >= t.ratio_s1 or creat_rise_48h >= t.rise_abs or coalesce(uo_hours_lt_0_5 >= t.uo_s1_h, false)`	creat_ratio=1.04, t.ratio_s1=1.5, creat_rise_48h=0.03, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, t.uo_s1_h=6	false
derived: stage3	`meets_definition and (creat_ratio >= t.ratio_s3 or creat_peak >= t.scr_s3 or rrt_started or coalesce(uo_hours_lt_0_3 >= t.uo_s3_h, false) or coalesce(anuria_hours >= t.anuria_h, false))`	meets_definition=False, creat_ratio=1.04, t.ratio_s3=3.0, creat_peak=0.78, t.scr_s3=4.0, rrt_started=False, uo_hours_lt_0_3=unknown, t.uo_s3_h=24, anuria_hours=unknown, t.anuria_h=12	false
derived: stage2	`creat_ratio >= t.ratio_s2 or coalesce(uo_hours_lt_0_5 >= t.uo_s2_h, false)`	creat_ratio=1.04, t.ratio_s2=2.0, uo_hours_lt_0_5=unknown, t.uo_s2_h=12	false
derived: stage	`case(stage3, 3, stage2, 2, meets_definition, 1, 0)`	stage3=False, stage2=False, meets_definition=False	0
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=0.03, t.rise_abs=0.3, rrt_started=False	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	stage=0, baseline_independent=True	false
outcome: aki_presumed_baseline	`stage >= 1`	stage=0	false
outcome: not_met	`stage == 0`	stage=0	true

Acute blood loss anaemia

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule blood_loss_anemia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: anaemic	`case(sex == 'M', hgb_nadir < t.hb_m, sex == 'F', hgb_nadir < t.hb_f, null)`	sex=F, hgb_nadir=13.39, t.hb_m=13, t.hb_f=12	false
derived: acute_fall	`hgb_drop >= t.drop_major or prbc_units >= t.prbc_major`	hgb_drop=0.3, t.drop_major=2.0, prbc_units=0, t.prbc_major=2	false
outcome: met	`bleeding_documented and anaemic and acute_fall`	bleeding_documented=False, anaemic=False, acute_fall=False	false
outcome: anaemia_only	`anaemic and hgb_drop < t.drop_min and prbc_units == 0`	anaemic=False, hgb_drop=0.3, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=13.39, anaemic=False	true

Chronic kidney disease

Clinical judgement required

No gap

Not documented; egfr 60 or above; ckd g1-g2 requires markers of kidney damage, which are not assessed here.

Trace

Rule trace (rule ckd v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: chronic	`egfr_n >= 2 and egfr_span_days >= t.chronic_days`	egfr_n=2, egfr_span_days=355, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=80.2, egfr_late=78.9	80.2
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=80.2, t.g2=60, egfr_late=78.9	false
derived: category	`case(staging_egfr >= t.g2, 'G1-G2', staging_egfr >= t.g3a, 'G3a', staging_egfr >= t.g3b, 'G3b', staging_egfr >= t.g4, 'G4', 'G5')`	staging_egfr=80.2, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15	G1-G2
outcome: duration_not_shown	`not chronic`	chronic=True	false
outcome: straddles_60	`not both_below_60 and min(egfr_early, egfr_late) < t.g2`	both_below_60=False, egfr_early=80.2, egfr_late=78.9, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=80.2, t.g2=60	true

Heart failure

Criteria met

Specificity gap

Documented “diastolic heart failure” (I50.30); criteria support the more specific Acute on chronic diastolic (HFpEF) heart failure (I50.33).

Trace

Rule trace (rule heart_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: np_elevated	`coalesce(bnp_max >= t.bnp, false) or coalesce(ntprobnp_max >= t.ntprobnp, false)`	bnp_max=1778.0, t.bnp=100, ntprobnp_max=unknown, t.ntprobnp=300	true
derived: acute_count	`count(iv_loop_diuretic, np_elevated, new_o2)`	iv_loop_diuretic=True, np_elevated=True, new_o2=False	2
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=62.0, t.ref=40, t.pres=50	diastolic
derived: improved	`coalesce(lvef_prior_min <= t.ref and lvef > t.ref and lvef - lvef_prior_min >= t.improved_rise, false)`	lvef_prior_min=unknown, t.ref=40, lvef=62.0, t.improved_rise=10	false
derived: acuity	`case(acute_count >= 2 and hf_history, 'acute on chronic', acute_count >= 2, 'acute', acute_count == 0 and hf_history, 'chronic', null)`	acute_count=2, hf_history=True	acute on chronic
outcome: improved_ef	`improved`	improved=False	false
outcome: midrange	`hf_type == 'midrange'`	hf_type=diastolic	false
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	hf_type=diastolic, acuity=acute on chronic	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	hf_type=diastolic, acuity=acute on chronic	false
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	hf_type=diastolic, acuity=acute on chronic	false
outcome: dia_aoc	`hf_type == 'diastolic' and acuity == 'acute on chronic'`	hf_type=diastolic, acuity=acute on chronic	true

Hyponatraemia

Criteria met

Specificity gap

Criteria support Hyponatraemia (moderate) (E87.1); no corresponding diagnosis is documented.

Trace

Rule trace (rule hyponatremia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: severity	`case(na_min < t.profound, 'profound', na_min < t.moderate, 'moderate', na_min < t.low, 'mild', 'none')`	na_min=126.0, t.profound=125, t.moderate=130, t.low=135	moderate
outcome: met	`na_min < t.low and na_low_count >= t.repeat and na_treated`	na_min=126.0, t.low=135, na_low_count=6, t.repeat=2, na_treated=True	true

Malnutrition

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

Trace

Rule trace (rule malnutrition v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: a_sev_intake	`intake_pct <= t.a_sev_intake_pct and intake_days >= t.a_sev_intake_days`	intake_pct=unknown, t.a_sev_intake_pct=50, intake_days=unknown, t.a_sev_intake_days=5	unknown
derived: a_mod_intake	`intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days`	intake_pct=unknown, t.a_mod_intake_pct=75, intake_days=unknown, t.a_mod_intake_days=7	unknown
derived: a_sev_wt	`(wt_loss_days <= 7 and wt_loss_pct > 2) or (wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: a_mod_wt	`(wt_loss_days <= 7 and wt_loss_pct >= 1) or (wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: c_sev_intake	`intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=unknown, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30	unknown
derived: c_mod_intake	`intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=unknown, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30	unknown
derived: c_sev_wt	`(wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5) or (wt_loss_days <= 183 and wt_loss_pct > 10) or (wt_loss_days <= 366 and wt_loss_pct > 20)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: c_mod_wt	`(wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5) or (wt_loss_days <= 183 and wt_loss_pct >= 10) or (wt_loss_days <= 366 and wt_loss_pct >= 20)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: n_assessed	`known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced)`	intake_pct=unknown, wt_loss_pct=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown	0
derived: n_severe	`case(nutr_context == 'acute', count(a_sev_intake, a_sev_wt, fat_loss >= 2, muscle_loss >= 2, fluid >= 2, grip_reduced), nutr_context == 'chronic', count(c_sev_intake, c_sev_wt, fat_loss >= 3, muscle_loss >= 3, fluid >= 3, grip_reduced), null)`	nutr_context=unknown, a_sev_intake=unknown, a_sev_wt=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown, c_sev_intake=unknown, c_sev_wt=unknown	unknown
derived: n_moderate	`case(nutr_context == 'acute', count(a_sev_intake or a_mod_intake, a_sev_wt or a_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), nutr_context == 'chronic', count(c_sev_intake or c_mod_intake, c_sev_wt or c_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), null)`	nutr_context=unknown, a_sev_intake=unknown, a_mod_intake=unknown, a_sev_wt=unknown, a_mod_wt=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown, c_sev_intake=unknown, c_mod_intake=unknown, c_sev_wt=unknown, c_mod_wt=unknown	unknown
outcome: severe	`n_severe >= 2`	n_severe=unknown	unknown
outcome: moderate	`n_moderate >= 2`	n_moderate=unknown	unknown
outcome: one_characteristic	`n_moderate == 1`	n_moderate=unknown	unknown
outcome: not_met	`n_moderate == 0 and n_assessed >= 2`	n_moderate=unknown, n_assessed=0	false

Obesity

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule obesity v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
outcome: not_adult	`age < t.adult`	age=83, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=23.9, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=23.9, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=23.9, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=23.9, t.c1=30	true

Pressure injury

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

Trace

Rule trace (rule pressure_injury v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: sacral	`wound_site == 'sacral'`	wound_site=unknown	unknown
outcome: no_wound_note	`not present(wound_stage)`	wound_stage=unknown	true

Acute respiratory failure

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule respiratory_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: measured	`present(spo2_min_ra) or present(pao2_min_ra) or present(pf_min)`	spo2_min_ra=94.0, pao2_min_ra=unknown, pf_min=unknown	true
derived: hypoxemia	`coalesce(spo2_min_ra < t.spo2_ra, false) or coalesce(pao2_min_ra < t.pao2, false) or coalesce(pf_min < t.pf, false)`	spo2_min_ra=94.0, t.spo2_ra=88, pao2_min_ra=unknown, t.pao2=60, pf_min=unknown, t.pf=300	false
derived: distress	`coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support`	rr_max=20.0, t.rr_distress=28, wob_increased=unknown, adv_resp_support=False	false
outcome: chronic_baseline	`home_o2 and hypoxemia`	home_o2=False, hypoxemia=False	false
outcome: met	`hypoxemia and distress`	hypoxemia=False, distress=False	false
outcome: hypoxemia_only	`hypoxemia`	hypoxemia=False	false
outcome: not_met	`measured and not hypoxemia and o2_max_lpm <= t.o2_low and not adv_resp_support`	measured=True, hypoxemia=False, o2_max_lpm=0.0, t.o2_low=2, adv_resp_support=False	true

Sepsis

Criteria not met

Clinical validation gap

Documented “sepsis” (A41.9) but the criteria are not met: Neither definition met: 0 SIRS criteria, SOFA change 0.

Trace

Rule trace (rule sepsis v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: sirs_temp	`coalesce(temp_max_48h > t.t_hi, false) or coalesce(temp_min_48h < t.t_lo, false)`	temp_max_48h=37.6, t.t_hi=38, temp_min_48h=36.6, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=86.0, t.hr=90	false
derived: sirs_rr	`coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false)`	rr_max_48h=20.0, t.rr=20, paco2_min_48h=unknown, t.paco2=32	false
derived: sirs_wbc	`coalesce(wbc_max_48h > t.wbc_hi, false) or coalesce(wbc_min_48h < t.wbc_lo, false) or coalesce(bands_max_48h > t.bands, false)`	wbc_max_48h=9.01, t.wbc_hi=12, wbc_min_48h=6.9, t.wbc_lo=4, bands_max_48h=unknown, t.bands=10	false
derived: sirs_count	`count(sirs_temp, sirs_hr, sirs_rr, sirs_wbc)`	sirs_temp=False, sirs_hr=False, sirs_rr=False, sirs_wbc=False	0
derived: sofa_resp	`coalesce(case(pf_min_48h < 100 and adv_resp_support, 4, pf_min_48h < 200 and adv_resp_support, 3, pf_min_48h < 300, 2, pf_min_48h < 400, 1, 0), 0)`	pf_min_48h=unknown, adv_resp_support=False	0
derived: sofa_coag	`coalesce(case(platelets_min_48h < 20, 4, platelets_min_48h < 50, 3, platelets_min_48h < 100, 2, platelets_min_48h < 150, 1, 0), 0)`	platelets_min_48h=177.0	0
derived: sofa_liver	`coalesce(case(bili_max_48h >= 12, 4, bili_max_48h >= 6, 3, bili_max_48h >= 2, 2, bili_max_48h >= 1.2, 1, 0), 0)`	bili_max_48h=0.76	0
derived: sofa_cardio	`coalesce(case(norepi_max_48h > 0.1, 4, norepi_max_48h > 0, 3, map_min_48h < 70, 1, 0), 0)`	norepi_max_48h=0.0, map_min_48h=82.0	0
derived: sofa_cns	`coalesce(case(gcs_min_48h < 6, 4, gcs_min_48h < 10, 3, gcs_min_48h < 13, 2, gcs_min_48h < 15, 1, 0), 0)`	gcs_min_48h=15.0	0
derived: sofa_renal	`coalesce(case(creat_max_48h >= 5, 4, creat_max_48h >= 3.5, 3, creat_max_48h >= 2, 2, creat_max_48h >= 1.2, 1, 0), 0)`	creat_max_48h=0.77	0
derived: sofa_renal_baseline	`coalesce(case(creat_baseline >= 5, 4, creat_baseline >= 3.5, 3, creat_baseline >= 2, 2, creat_baseline >= 1.2, 1, 0), 0)`	creat_baseline=0.75	0
derived: sofa_delta	`sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline`	sofa_resp=0, sofa_coag=0, sofa_liver=0, sofa_cardio=0, sofa_cns=0, sofa_renal=0, sofa_renal_baseline=0	0
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=0, t.sofa_delta=2	false
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=True, sirs_count=0, t.sirs_min=2	false
derived: shock	`sepsis3 and norepi_max_48h > 0 and coalesce(lactate_max_48h > t.lactate, false)`	sepsis3=False, norepi_max_48h=0.0, lactate_max_48h=unknown, t.lactate=2	false
outcome: no_infection	`not infection_documented`	infection_documented=True	false
outcome: septic_shock	`shock`	shock=False	false
outcome: both	`sepsis3 and sepsis2`	sepsis3=False, sepsis2=False	false
outcome: sepsis3_only	`sepsis3`	sepsis3=False	false
outcome: definitions_disagree	`sepsis2`	sepsis2=False	false
outcome: neither	`true`	—	true

Structured data

Labs (44)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-000108	Mon Sep 15, 2025 09:15 AM	creatinine	0.74 mg/dL
LAB-000109	Sat Sep 05, 2026 10:05 AM	creatinine	0.75 mg/dL
LAB-000110	Thu Oct 29, 2026 01:49 PM	creatinine	0.75 mg/dL
LAB-000118	Thu Oct 29, 2026 01:49 PM	bnp	1778.0 pg/mL
LAB-000119	Thu Oct 29, 2026 01:49 PM	sodium	128.0 mmol/L
LAB-000127	Thu Oct 29, 2026 01:49 PM	hemoglobin	13.65 g/dL
LAB-000135	Thu Oct 29, 2026 01:49 PM	wbc	9.01 x10^3/uL
LAB-000136	Thu Oct 29, 2026 01:49 PM	platelets	198.0 x10^3/uL
LAB-000151	Thu Oct 29, 2026 01:49 PM	bilirubin	0.76 mg/dL
LAB-000111	Fri Oct 30, 2026 05:00 AM	creatinine	0.74 mg/dL
LAB-000120	Fri Oct 30, 2026 05:00 AM	sodium	126.0 mmol/L
LAB-000128	Fri Oct 30, 2026 05:00 AM	hemoglobin	13.72 g/dL
LAB-000137	Fri Oct 30, 2026 05:00 AM	wbc	8.69 x10^3/uL
LAB-000138	Fri Oct 30, 2026 05:00 AM	platelets	177.0 x10^3/uL
LAB-000112	Sat Oct 31, 2026 05:00 AM	creatinine	0.77 mg/dL
LAB-000121	Sat Oct 31, 2026 05:00 AM	sodium	127.0 mmol/L
LAB-000129	Sat Oct 31, 2026 05:00 AM	hemoglobin	13.4 g/dL
LAB-000139	Sat Oct 31, 2026 05:00 AM	wbc	6.9 x10^3/uL
LAB-000140	Sat Oct 31, 2026 05:00 AM	platelets	253.0 x10^3/uL
LAB-000113	Sun Nov 01, 2026 05:00 AM	creatinine	0.76 mg/dL
LAB-000122	Sun Nov 01, 2026 05:00 AM	sodium	130.0 mmol/L
LAB-000130	Sun Nov 01, 2026 05:00 AM	hemoglobin	13.46 g/dL
LAB-000141	Sun Nov 01, 2026 05:00 AM	wbc	10.11 x10^3/uL
LAB-000142	Sun Nov 01, 2026 05:00 AM	platelets	180.0 x10^3/uL
LAB-000114	Mon Nov 02, 2026 05:00 AM	creatinine	0.78 mg/dL
LAB-000123	Mon Nov 02, 2026 05:00 AM	sodium	132.0 mmol/L
LAB-000131	Mon Nov 02, 2026 05:00 AM	hemoglobin	13.67 g/dL
LAB-000143	Mon Nov 02, 2026 05:00 AM	wbc	8.88 x10^3/uL
LAB-000144	Mon Nov 02, 2026 05:00 AM	platelets	240.0 x10^3/uL
LAB-000115	Tue Nov 03, 2026 05:00 AM	creatinine	0.75 mg/dL
LAB-000124	Tue Nov 03, 2026 05:00 AM	sodium	134.0 mmol/L
LAB-000132	Tue Nov 03, 2026 05:00 AM	hemoglobin	13.39 g/dL
LAB-000145	Tue Nov 03, 2026 05:00 AM	wbc	10.49 x10^3/uL
LAB-000146	Tue Nov 03, 2026 05:00 AM	platelets	228.0 x10^3/uL
LAB-000116	Wed Nov 04, 2026 05:00 AM	creatinine	0.76 mg/dL
LAB-000125	Wed Nov 04, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-000133	Wed Nov 04, 2026 05:00 AM	hemoglobin	13.47 g/dL
LAB-000147	Wed Nov 04, 2026 05:00 AM	wbc	8.86 x10^3/uL
LAB-000148	Wed Nov 04, 2026 05:00 AM	platelets	222.0 x10^3/uL
LAB-000117	Thu Nov 05, 2026 05:00 AM	creatinine	0.75 mg/dL
LAB-000126	Thu Nov 05, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-000134	Thu Nov 05, 2026 05:00 AM	hemoglobin	13.66 g/dL
LAB-000149	Thu Nov 05, 2026 05:00 AM	wbc	9.14 x10^3/uL
LAB-000150	Thu Nov 05, 2026 05:00 AM	platelets	232.0 x10^3/uL

Vitals (126)

Vitals
Row	When	Kind	Value	Detail
VIT-000305	Thu Oct 29, 2026 01:09 PM	spo2	98.0	room air
VIT-000306	Thu Oct 29, 2026 01:09 PM	rr	20.0
VIT-000347	Thu Oct 29, 2026 01:09 PM	temp_c	36.6
VIT-000348	Thu Oct 29, 2026 01:09 PM	hr	85.0
VIT-000349	Thu Oct 29, 2026 01:09 PM	map	82.0
VIT-000350	Thu Oct 29, 2026 01:09 PM	gcs	15.0
VIT-000307	Thu Oct 29, 2026 09:09 PM	spo2	95.0	room air
VIT-000308	Thu Oct 29, 2026 09:09 PM	rr	14.0
VIT-000351	Thu Oct 29, 2026 09:09 PM	temp_c	36.8
VIT-000352	Thu Oct 29, 2026 09:09 PM	hr	86.0
VIT-000353	Thu Oct 29, 2026 09:09 PM	map	89.0
VIT-000354	Thu Oct 29, 2026 09:09 PM	gcs	15.0
VIT-000309	Fri Oct 30, 2026 05:09 AM	spo2	95.0	room air
VIT-000310	Fri Oct 30, 2026 05:09 AM	rr	17.0
VIT-000355	Fri Oct 30, 2026 05:09 AM	temp_c	37.4
VIT-000356	Fri Oct 30, 2026 05:09 AM	hr	84.0
VIT-000357	Fri Oct 30, 2026 05:09 AM	map	87.0
VIT-000358	Fri Oct 30, 2026 05:09 AM	gcs	15.0
VIT-000311	Fri Oct 30, 2026 01:09 PM	spo2	94.0	room air
VIT-000312	Fri Oct 30, 2026 01:09 PM	rr	15.0
VIT-000359	Fri Oct 30, 2026 01:09 PM	temp_c	37.5
VIT-000360	Fri Oct 30, 2026 01:09 PM	hr	82.0
VIT-000361	Fri Oct 30, 2026 01:09 PM	map	91.0
VIT-000362	Fri Oct 30, 2026 01:09 PM	gcs	15.0
VIT-000313	Fri Oct 30, 2026 09:09 PM	spo2	96.0	room air
VIT-000314	Fri Oct 30, 2026 09:09 PM	rr	16.0
VIT-000363	Fri Oct 30, 2026 09:09 PM	temp_c	36.9
VIT-000364	Fri Oct 30, 2026 09:09 PM	hr	74.0
VIT-000365	Fri Oct 30, 2026 09:09 PM	map	82.0
VIT-000366	Fri Oct 30, 2026 09:09 PM	gcs	15.0
VIT-000315	Sat Oct 31, 2026 05:09 AM	spo2	98.0	room air
VIT-000316	Sat Oct 31, 2026 05:09 AM	rr	20.0
VIT-000367	Sat Oct 31, 2026 05:09 AM	temp_c	37.6
VIT-000368	Sat Oct 31, 2026 05:09 AM	hr	83.0
VIT-000369	Sat Oct 31, 2026 05:09 AM	map	90.0
VIT-000370	Sat Oct 31, 2026 05:09 AM	gcs	15.0
VIT-000317	Sat Oct 31, 2026 01:09 PM	spo2	99.0	room air
VIT-000318	Sat Oct 31, 2026 01:09 PM	rr	15.0
VIT-000371	Sat Oct 31, 2026 01:09 PM	temp_c	36.9
VIT-000372	Sat Oct 31, 2026 01:09 PM	hr	83.0
VIT-000373	Sat Oct 31, 2026 01:09 PM	map	88.0
VIT-000374	Sat Oct 31, 2026 01:09 PM	gcs	15.0
VIT-000319	Sat Oct 31, 2026 09:09 PM	spo2	94.0	room air
VIT-000320	Sat Oct 31, 2026 09:09 PM	rr	19.0
VIT-000375	Sat Oct 31, 2026 09:09 PM	temp_c	37.4
VIT-000376	Sat Oct 31, 2026 09:09 PM	hr	75.0
VIT-000377	Sat Oct 31, 2026 09:09 PM	map	79.0
VIT-000378	Sat Oct 31, 2026 09:09 PM	gcs	15.0
VIT-000321	Sun Nov 01, 2026 05:09 AM	spo2	95.0	room air
VIT-000322	Sun Nov 01, 2026 05:09 AM	rr	16.0
VIT-000379	Sun Nov 01, 2026 05:09 AM	temp_c	36.7
VIT-000380	Sun Nov 01, 2026 05:09 AM	hr	78.0
VIT-000381	Sun Nov 01, 2026 05:09 AM	map	90.0
VIT-000382	Sun Nov 01, 2026 05:09 AM	gcs	15.0
VIT-000323	Sun Nov 01, 2026 01:09 PM	spo2	98.0	room air
VIT-000324	Sun Nov 01, 2026 01:09 PM	rr	17.0
VIT-000383	Sun Nov 01, 2026 01:09 PM	temp_c	37.0
VIT-000384	Sun Nov 01, 2026 01:09 PM	hr	86.0
VIT-000385	Sun Nov 01, 2026 01:09 PM	map	88.0
VIT-000386	Sun Nov 01, 2026 01:09 PM	gcs	15.0
VIT-000325	Sun Nov 01, 2026 09:09 PM	spo2	96.0	room air
VIT-000326	Sun Nov 01, 2026 09:09 PM	rr	17.0
VIT-000387	Sun Nov 01, 2026 09:09 PM	temp_c	37.3
VIT-000388	Sun Nov 01, 2026 09:09 PM	hr	86.0
VIT-000389	Sun Nov 01, 2026 09:09 PM	map	83.0
VIT-000390	Sun Nov 01, 2026 09:09 PM	gcs	15.0
VIT-000327	Mon Nov 02, 2026 05:09 AM	spo2	96.0	room air
VIT-000328	Mon Nov 02, 2026 05:09 AM	rr	16.0
VIT-000391	Mon Nov 02, 2026 05:09 AM	temp_c	36.9
VIT-000392	Mon Nov 02, 2026 05:09 AM	hr	88.0
VIT-000393	Mon Nov 02, 2026 05:09 AM	map	90.0
VIT-000394	Mon Nov 02, 2026 05:09 AM	gcs	15.0
VIT-000329	Mon Nov 02, 2026 01:09 PM	spo2	98.0	room air
VIT-000330	Mon Nov 02, 2026 01:09 PM	rr	18.0
VIT-000395	Mon Nov 02, 2026 01:09 PM	temp_c	37.1
VIT-000396	Mon Nov 02, 2026 01:09 PM	hr	74.0
VIT-000397	Mon Nov 02, 2026 01:09 PM	map	78.0
VIT-000398	Mon Nov 02, 2026 01:09 PM	gcs	15.0
VIT-000331	Mon Nov 02, 2026 09:09 PM	spo2	95.0	room air
VIT-000332	Mon Nov 02, 2026 09:09 PM	rr	20.0
VIT-000399	Mon Nov 02, 2026 09:09 PM	temp_c	36.6
VIT-000400	Mon Nov 02, 2026 09:09 PM	hr	72.0
VIT-000401	Mon Nov 02, 2026 09:09 PM	map	89.0
VIT-000402	Mon Nov 02, 2026 09:09 PM	gcs	15.0
VIT-000333	Tue Nov 03, 2026 05:09 AM	spo2	97.0	room air
VIT-000334	Tue Nov 03, 2026 05:09 AM	rr	18.0
VIT-000403	Tue Nov 03, 2026 05:09 AM	temp_c	36.6
VIT-000404	Tue Nov 03, 2026 05:09 AM	hr	81.0
VIT-000405	Tue Nov 03, 2026 05:09 AM	map	86.0
VIT-000406	Tue Nov 03, 2026 05:09 AM	gcs	15.0
VIT-000335	Tue Nov 03, 2026 01:09 PM	spo2	94.0	room air
VIT-000336	Tue Nov 03, 2026 01:09 PM	rr	18.0
VIT-000407	Tue Nov 03, 2026 01:09 PM	temp_c	37.1
VIT-000408	Tue Nov 03, 2026 01:09 PM	hr	74.0
VIT-000409	Tue Nov 03, 2026 01:09 PM	map	77.0
VIT-000410	Tue Nov 03, 2026 01:09 PM	gcs	15.0
VIT-000337	Tue Nov 03, 2026 09:09 PM	spo2	94.0	room air
VIT-000338	Tue Nov 03, 2026 09:09 PM	rr	19.0
VIT-000411	Tue Nov 03, 2026 09:09 PM	temp_c	36.7
VIT-000412	Tue Nov 03, 2026 09:09 PM	hr	80.0
VIT-000413	Tue Nov 03, 2026 09:09 PM	map	77.0
VIT-000414	Tue Nov 03, 2026 09:09 PM	gcs	15.0
VIT-000339	Wed Nov 04, 2026 05:09 AM	spo2	98.0	room air
VIT-000340	Wed Nov 04, 2026 05:09 AM	rr	19.0
VIT-000415	Wed Nov 04, 2026 05:09 AM	temp_c	37.0
VIT-000416	Wed Nov 04, 2026 05:09 AM	hr	85.0
VIT-000417	Wed Nov 04, 2026 05:09 AM	map	78.0
VIT-000418	Wed Nov 04, 2026 05:09 AM	gcs	15.0
VIT-000341	Wed Nov 04, 2026 01:09 PM	spo2	98.0	room air
VIT-000342	Wed Nov 04, 2026 01:09 PM	rr	18.0
VIT-000419	Wed Nov 04, 2026 01:09 PM	temp_c	36.9
VIT-000420	Wed Nov 04, 2026 01:09 PM	hr	86.0
VIT-000421	Wed Nov 04, 2026 01:09 PM	map	84.0
VIT-000422	Wed Nov 04, 2026 01:09 PM	gcs	15.0
VIT-000343	Wed Nov 04, 2026 09:09 PM	spo2	94.0	room air
VIT-000344	Wed Nov 04, 2026 09:09 PM	rr	16.0
VIT-000423	Wed Nov 04, 2026 09:09 PM	temp_c	36.6
VIT-000424	Wed Nov 04, 2026 09:09 PM	hr	80.0
VIT-000425	Wed Nov 04, 2026 09:09 PM	map	82.0
VIT-000426	Wed Nov 04, 2026 09:09 PM	gcs	15.0
VIT-000345	Thu Nov 05, 2026 05:09 AM	spo2	98.0	room air
VIT-000346	Thu Nov 05, 2026 05:09 AM	rr	20.0
VIT-000427	Thu Nov 05, 2026 05:09 AM	temp_c	36.8
VIT-000428	Thu Nov 05, 2026 05:09 AM	hr	72.0
VIT-000429	Thu Nov 05, 2026 05:09 AM	map	82.0
VIT-000430	Thu Nov 05, 2026 05:09 AM	gcs	15.0

Medications, orders, echo, history (13)

MED-000022 10-29 13:49 ceftriaxone per protocol IV
MED-000023 10-30 05:00 piperacillin-tazobactam per protocol IV
MED-000024 10-31 05:00 ceftriaxone per protocol IV
MED-000025 10-29 08:00 furosemide 40 mg IV
MED-000026 10-29 20:00 furosemide 40 mg IV
MED-000027 10-30 08:00 furosemide 40 mg IV
MED-000028 10-30 20:00 furosemide 40 mg IV
MED-000029 10-31 08:00 furosemide 40 mg IV
MED-000030 10-31 20:00 furosemide 40 mg IV
ORD-000002 10-29 13:19 blood_culture: blood cultures x2
ORD-000003 10-29 15:49 fluid_restriction: fluid restriction 1.2 L/day
ECH-000004 2026-10-30 echo LVEF 62.0%
HX-000004 history: heart failure with preserved ejection fraction

Notes

History and physical · DOC-000012 · Dr. Cyrus Ellingham (attending) · Thu Oct 29, 2026 03:49 PM

Cited facts from this note (1)

infection_source: acute pyelonephritis · cited p. 1, line 5 · confidence 0.85

Show source for infection_source

… ce: Hospital Medicine Attending: Dr. Cyrus Ellingham History of present illness: 83-year-old woman admitted with sepsis. Urinalysis with pyuria; treated for acute pyelonephritis with cefepime. Past medical history: heart failure with preserved ejection fraction, hypertension, hyperlipidemia. Review of systems otherwise negative. Exam: …

Source document DOC-000012: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Luca Abernath   MRN: MRN29573051   Admitted: 2026-10-29 12:49
Service: Hospital Medicine   Attending: Dr. Cyrus Ellingham

History of present illness: 83-year-old woman admitted with sepsis. Urinalysis with pyuria; treated for acute pyelonephritis with cefepime.
Past medical history: heart failure with preserved ejection fraction, hypertension, hyperlipidemia.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Sepsis: antibiotics, fluids.
2. Urinary tract infection: antibiotics.

Progress note · DOC-000013 · Dr. Cyrus Ellingham (attending) · Sat Oct 31, 2026 12:49 PM

Source document DOC-000013: Progress note (synthetic)

PROGRESS NOTE (Attending)
Patient: Luca Abernath   MRN: MRN29573051   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.
2. Diastolic heart failure: diuresis and daily weights; monitor electrolytes.

Attending: Dr. Cyrus Ellingham

Discharge summary · DOC-000014 · Dr. Cyrus Ellingham (attending) · Thu Nov 05, 2026 12:42 PM

Source document DOC-000014: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Luca Abernath   MRN: MRN29573051
Admitted 2026-10-29; discharged 2026-11-05.

Discharge diagnoses:
- sepsis
- urinary tract infection
- diastolic heart failure
- hypertension
- hyperlipidemia

Disposition: home with follow-up.