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-00030: Camila Merriweather

72M · MRN75241283 · Hospital Medicine · admitted Sun Nov 08, 2026 02:47 PM · discharged Wed Nov 11, 2026 11:14 AM · attending Dr. Kenji Stavros · resident Dr. Camila Oyelaran · 178 cm, 99.0 kg

Documented diagnoses (current)

Principal: “sepsis” · A41.9 Sepsis, unspecified organism
“urinary tract infection” · N39.0 Urinary tract infection, site not specified
“obesity” · E66.9 Obesity, unspecified
“acute on chronic diastolic heart failure” · I50.33 Acute on chronic diastolic (congestive) heart failure
“hypertension” · I10 Essential (primary) hypertension
“hyperlipidemia” · E78.5 Hyperlipidemia, unspecified
“type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications

Illustrative grouping now: MS-DRG 871 Septicemia or severe sepsis without MV >96 hours with 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=1.045, t.ratio_s1=1.5, creat_rise_48h=0.07, 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=1.045, t.ratio_s3=3.0, creat_peak=2.81, 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=1.045, 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=0.07, 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=M, hgb_nadir=14.66, 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=0.0, 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=0.0, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=14.66, anaemic=False	true

Chronic kidney disease

Criteria met

Specificity gap

Criteria support Chronic kidney disease stage 4 (N18.4); no corresponding diagnosis is documented.

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=239, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=24.2, egfr_late=24.4	24.4
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=24.2, t.g2=60, egfr_late=24.4	true
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=24.4, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15	G4
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=True, egfr_early=24.2, egfr_late=24.4, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=24.4, t.g2=60	false
outcome: g3a	`category == 'G3a'`	category=G4	false
outcome: g3b	`category == 'G3b'`	category=G4	false
outcome: g4	`category == 'G4'`	category=G4	true

Heart failure

Criteria met

No gap

Supported as documented (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=1002.0, 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=63.0, 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=63.0, 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 not met

No gap

Not documented and not supported.

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=138.0, t.profound=125, t.moderate=130, t.low=135	none
outcome: met	`na_min < t.low and na_low_count >= t.repeat and na_treated`	na_min=138.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=138.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=138.0, t.low=135	true

Malnutrition

Criteria not met

No gap

Not documented and not supported.

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=100.0, t.a_sev_intake_pct=50, intake_days=unknown, t.a_sev_intake_days=5	false
derived: a_mod_intake	`intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days`	intake_pct=100.0, t.a_mod_intake_pct=75, intake_days=unknown, t.a_mod_intake_days=7	false
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=100.0, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30	false
derived: c_mod_intake	`intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=100.0, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30	false
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=100.0, wt_loss_pct=unknown, fat_loss=0, muscle_loss=0, fluid=0, grip_reduced=unknown	4
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=acute, a_sev_intake=False, a_sev_wt=unknown, fat_loss=0, muscle_loss=0, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_sev_wt=unknown	0
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=acute, a_sev_intake=False, a_mod_intake=False, a_sev_wt=unknown, a_mod_wt=unknown, fat_loss=0, muscle_loss=0, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_mod_intake=False, c_sev_wt=unknown, c_mod_wt=unknown	0
outcome: severe	`n_severe >= 2`	n_severe=0	false
outcome: moderate	`n_moderate >= 2`	n_moderate=0	false
outcome: one_characteristic	`n_moderate == 1`	n_moderate=0	false
outcome: not_met	`n_moderate == 0 and n_assessed >= 2`	n_moderate=0, n_assessed=4	true

Obesity

Criteria met

Specificity gap

Documented “obesity” (E66.9); criteria support the more specific Obesity, class 1 (E66.811).

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=72, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=31.2, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=31.2, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=31.2, 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=37.5, t.t_hi=38, temp_min_48h=36.7, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=88.0, 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=9.32, t.wbc_hi=12, wbc_min_48h=7.52, 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=174.0	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=0.72	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=75.0	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=2.81	2
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=2.69	2
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=2, sofa_renal_baseline=2	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 (24)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-001016	Wed Jan 07, 2026 09:15 AM	creatinine	2.71 mg/dL
LAB-001017	Fri Sep 04, 2026 10:05 AM	creatinine	2.69 mg/dL
LAB-001018	Sun Nov 08, 2026 03:47 PM	creatinine	2.79 mg/dL
LAB-001022	Sun Nov 08, 2026 03:47 PM	bnp	1002.0 pg/mL
LAB-001023	Sun Nov 08, 2026 03:47 PM	sodium	142.0 mmol/L
LAB-001027	Sun Nov 08, 2026 03:47 PM	hemoglobin	14.66 g/dL
LAB-001031	Sun Nov 08, 2026 03:47 PM	wbc	8.32 x10^3/uL
LAB-001032	Sun Nov 08, 2026 03:47 PM	platelets	273.0 x10^3/uL
LAB-001039	Sun Nov 08, 2026 03:47 PM	bilirubin	0.72 mg/dL
LAB-001019	Mon Nov 09, 2026 05:00 AM	creatinine	2.74 mg/dL
LAB-001024	Mon Nov 09, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-001028	Mon Nov 09, 2026 05:00 AM	hemoglobin	14.96 g/dL
LAB-001033	Mon Nov 09, 2026 05:00 AM	wbc	7.52 x10^3/uL
LAB-001034	Mon Nov 09, 2026 05:00 AM	platelets	174.0 x10^3/uL
LAB-001020	Tue Nov 10, 2026 05:00 AM	creatinine	2.81 mg/dL
LAB-001025	Tue Nov 10, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-001029	Tue Nov 10, 2026 05:00 AM	hemoglobin	14.99 g/dL
LAB-001035	Tue Nov 10, 2026 05:00 AM	wbc	9.32 x10^3/uL
LAB-001036	Tue Nov 10, 2026 05:00 AM	platelets	285.0 x10^3/uL
LAB-001021	Wed Nov 11, 2026 05:00 AM	creatinine	2.72 mg/dL
LAB-001026	Wed Nov 11, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-001030	Wed Nov 11, 2026 05:00 AM	hemoglobin	14.86 g/dL
LAB-001037	Wed Nov 11, 2026 05:00 AM	wbc	9.71 x10^3/uL
LAB-001038	Wed Nov 11, 2026 05:00 AM	platelets	235.0 x10^3/uL

Vitals (54)

Vitals
Row	When	Kind	Value	Detail
VIT-002930	Sun Nov 08, 2026 03:07 PM	spo2	98.0	room air
VIT-002931	Sun Nov 08, 2026 03:07 PM	rr	19.0
VIT-002948	Sun Nov 08, 2026 03:07 PM	temp_c	36.7
VIT-002949	Sun Nov 08, 2026 03:07 PM	hr	88.0
VIT-002950	Sun Nov 08, 2026 03:07 PM	map	75.0
VIT-002951	Sun Nov 08, 2026 03:07 PM	gcs	15.0
VIT-002932	Sun Nov 08, 2026 11:07 PM	spo2	95.0	room air
VIT-002933	Sun Nov 08, 2026 11:07 PM	rr	15.0
VIT-002952	Sun Nov 08, 2026 11:07 PM	temp_c	36.9
VIT-002953	Sun Nov 08, 2026 11:07 PM	hr	78.0
VIT-002954	Sun Nov 08, 2026 11:07 PM	map	88.0
VIT-002955	Sun Nov 08, 2026 11:07 PM	gcs	15.0
VIT-002934	Mon Nov 09, 2026 07:07 AM	spo2	94.0	room air
VIT-002935	Mon Nov 09, 2026 07:07 AM	rr	20.0
VIT-002956	Mon Nov 09, 2026 07:07 AM	temp_c	36.8
VIT-002957	Mon Nov 09, 2026 07:07 AM	hr	84.0
VIT-002958	Mon Nov 09, 2026 07:07 AM	map	85.0
VIT-002959	Mon Nov 09, 2026 07:07 AM	gcs	15.0
VIT-002936	Mon Nov 09, 2026 03:07 PM	spo2	95.0	room air
VIT-002937	Mon Nov 09, 2026 03:07 PM	rr	16.0
VIT-002960	Mon Nov 09, 2026 03:07 PM	temp_c	37.3
VIT-002961	Mon Nov 09, 2026 03:07 PM	hr	87.0
VIT-002962	Mon Nov 09, 2026 03:07 PM	map	83.0
VIT-002963	Mon Nov 09, 2026 03:07 PM	gcs	15.0
VIT-002938	Mon Nov 09, 2026 11:07 PM	spo2	96.0	room air
VIT-002939	Mon Nov 09, 2026 11:07 PM	rr	19.0
VIT-002964	Mon Nov 09, 2026 11:07 PM	temp_c	37.5
VIT-002965	Mon Nov 09, 2026 11:07 PM	hr	85.0
VIT-002966	Mon Nov 09, 2026 11:07 PM	map	79.0
VIT-002967	Mon Nov 09, 2026 11:07 PM	gcs	15.0
VIT-002940	Tue Nov 10, 2026 07:07 AM	spo2	95.0	room air
VIT-002941	Tue Nov 10, 2026 07:07 AM	rr	19.0
VIT-002968	Tue Nov 10, 2026 07:07 AM	temp_c	36.7
VIT-002969	Tue Nov 10, 2026 07:07 AM	hr	75.0
VIT-002970	Tue Nov 10, 2026 07:07 AM	map	80.0
VIT-002971	Tue Nov 10, 2026 07:07 AM	gcs	15.0
VIT-002942	Tue Nov 10, 2026 03:07 PM	spo2	98.0	room air
VIT-002943	Tue Nov 10, 2026 03:07 PM	rr	16.0
VIT-002972	Tue Nov 10, 2026 03:07 PM	temp_c	36.7
VIT-002973	Tue Nov 10, 2026 03:07 PM	hr	75.0
VIT-002974	Tue Nov 10, 2026 03:07 PM	map	81.0
VIT-002975	Tue Nov 10, 2026 03:07 PM	gcs	15.0
VIT-002944	Tue Nov 10, 2026 11:07 PM	spo2	97.0	room air
VIT-002945	Tue Nov 10, 2026 11:07 PM	rr	16.0
VIT-002976	Tue Nov 10, 2026 11:07 PM	temp_c	36.7
VIT-002977	Tue Nov 10, 2026 11:07 PM	hr	81.0
VIT-002978	Tue Nov 10, 2026 11:07 PM	map	84.0
VIT-002979	Tue Nov 10, 2026 11:07 PM	gcs	15.0
VIT-002946	Wed Nov 11, 2026 07:07 AM	spo2	96.0	room air
VIT-002947	Wed Nov 11, 2026 07:07 AM	rr	15.0
VIT-002980	Wed Nov 11, 2026 07:07 AM	temp_c	37.2
VIT-002981	Wed Nov 11, 2026 07:07 AM	hr	79.0
VIT-002982	Wed Nov 11, 2026 07:07 AM	map	89.0
VIT-002983	Wed Nov 11, 2026 07:07 AM	gcs	15.0

Medications, orders, echo, history (12)

MED-000109 11-08 15:47 ceftriaxone per protocol IV
MED-000110 11-09 05:00 piperacillin-tazobactam per protocol IV
MED-000111 11-10 05:00 ceftriaxone per protocol IV
MED-000112 11-08 08:00 furosemide 40 mg IV
MED-000113 11-08 20:00 furosemide 40 mg IV
MED-000114 11-09 08:00 furosemide 40 mg IV
MED-000115 11-09 20:00 furosemide 40 mg IV
MED-000116 11-10 08:00 furosemide 40 mg IV
MED-000117 11-10 20:00 furosemide 40 mg IV
ORD-000025 11-08 15:17 blood_culture: blood cultures x2
ECH-000013 2026-11-09 echo LVEF 63.0%
HX-000009 history: heart failure with preserved ejection fraction

Notes

History and physical · DOC-000100 · Dr. Camila Oyelaran (resident) · Sun Nov 08, 2026 05:47 PM

Cited facts from this note (1)

infection_source: urinary tract infection · cited p. 1, line 5 · confidence 0.85

Show source for infection_source

… ervice: Hospital Medicine Attending: Dr. Kenji Stavros History of present illness: 72-year-old man admitted with sepsis. Urinalysis with pyuria; treated for urinary tract infection with cefepime. Past medical history: heart failure with preserved ejection fraction, hypertension, hyperlipidemia, type 2 diabetes. Review of systems otherwise …

Source document DOC-000100: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Camila Merriweather   MRN: MRN75241283   Admitted: 2026-11-08 14:47
Service: Hospital Medicine   Attending: Dr. Kenji Stavros

History of present illness: 72-year-old man admitted with sepsis. Urinalysis with pyuria; treated for urinary tract infection with cefepime.
Past medical history: heart failure with preserved ejection fraction, hypertension, hyperlipidemia, type 2 diabetes.
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.

Nutrition assessment · DOC-000099 · Viggo Ravensworth, RD (dietitian) · Mon Nov 09, 2026 06:47 PM

Cited facts from this note (5)

fat_loss: none · cited p. 1, line 7 · confidence 0.90

Show source for fat_loss

… MRN: MRN75241283 Context: acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: well nourished; no malnutrition identified.
fluid_accumulation: none · cited p. 1, line 7 · confidence 0.90

Show source for fluid_accumulation

… e: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: well nourished; no malnutrition identified.
intake_pct: 100 · cited p. 1, line 5 · confidence 0.90

Show source for intake_pct

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Camila Merriweather MRN: MRN75241283 Context: acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. …
muscle_loss: none · cited p. 1, line 7 · confidence 0.90

Show source for muscle_loss

… acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: well nourished; no malnutrition identified.
nutrition_context: acute · cited p. 1, line 4 · confidence 0.95

Show source for nutrition_context

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Camila Merriweather MRN: MRN75241283 Context: acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle was …

Source document DOC-000099: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Camila Merriweather   MRN: MRN75241283

Context: acute illness
Intake: eating 100% of meals.
Weight history: weight stable over the past 3 months.
Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation.
Assessment: well nourished; no malnutrition identified.

Progress note · DOC-000101 · Dr. Camila Oyelaran (resident) · Tue Nov 10, 2026 05:47 PM

Source document DOC-000101: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Camila Merriweather   MRN: MRN75241283   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.
2. Obesity: counsel on weight.
3. Acute on chronic diastolic heart failure: diuresis and daily weights; monitor electrolytes.

Resident: Dr. Camila Oyelaran   Attending cosign: completed

Discharge summary · DOC-000102 · Dr. Kenji Stavros (attending) · Wed Nov 11, 2026 11:14 AM

Source document DOC-000102: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Camila Merriweather   MRN: MRN75241283
Admitted 2026-11-08; discharged 2026-11-11.

Discharge diagnoses:
- sepsis
- urinary tract infection
- obesity
- acute on chronic diastolic heart failure
- hypertension
- hyperlipidemia
- type 2 diabetes

Disposition: home with follow-up.