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-00036: Odette Penhallow

70M · MRN60628496 · Hospital Medicine · admitted Mon Nov 02, 2026 04:04 PM · discharged Thu Nov 05, 2026 01:26 PM · attending Dr. Wes Merriweather · resident Dr. Priya Thorne · 168 cm, 58.8 kg

Documented diagnoses (current)

Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“hypertension” · I10 Essential (primary) hypertension

Illustrative grouping now: MS-DRG 195 Simple pneumonia and pleurisy without CC/MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 195.

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=1.061, 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=1.061, t.ratio_s3=3.0, creat_peak=1.22, 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=1.061, 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=14.01, 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=0.4, 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=0.4, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=14.01, 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=240, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=70.7, egfr_late=68.5	70.7
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=70.7, t.g2=60, egfr_late=68.5	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=70.7, 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=70.7, egfr_late=68.5, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=70.7, t.g2=60	true

Heart failure

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

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=unknown, t.bnp=100, ntprobnp_max=unknown, t.ntprobnp=300	false
derived: acute_count	`count(iv_loop_diuretic, np_elevated, new_o2)`	iv_loop_diuretic=False, np_elevated=False, new_o2=False	0
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=unknown, t.ref=40, t.pres=50	unknown
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=unknown, 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=0, hf_history=False	unknown
outcome: improved_ef	`improved`	improved=False	false
outcome: midrange	`hf_type == 'midrange'`	hf_type=unknown	unknown
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	hf_type=unknown, acuity=unknown	unknown
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	hf_type=unknown, acuity=unknown	unknown
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	hf_type=unknown, acuity=unknown	unknown
outcome: dia_aoc	`hf_type == 'diastolic' and acuity == 'acute on chronic'`	hf_type=unknown, acuity=unknown	unknown
outcome: dia_acute	`hf_type == 'diastolic' and acuity == 'acute'`	hf_type=unknown, acuity=unknown	unknown
outcome: dia_chronic	`hf_type == 'diastolic' and acuity == 'chronic'`	hf_type=unknown, acuity=unknown	unknown
outcome: one_indicator	`acute_count == 1`	acute_count=0	false

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=136.0, 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=136.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=136.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=136.0, t.low=135	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=70, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=20.8, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=20.8, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=20.8, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=20.8, 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=95.0, 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=95.0, 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

No gap

Not documented and not supported.

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=89.0, 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=10.12, t.wbc_hi=12, wbc_min_48h=5.8, 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=239.0	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=0.63	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=77.0	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=1.22	1
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=1.15	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=1, sofa_renal_baseline=0	1
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=1, 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 (23)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-001229	Sat Nov 22, 2025 09:15 AM	creatinine	1.12 mg/dL
LAB-001230	Tue Jul 21, 2026 10:05 AM	creatinine	1.15 mg/dL
LAB-001231	Mon Nov 02, 2026 05:04 PM	creatinine	1.18 mg/dL
LAB-001235	Mon Nov 02, 2026 05:04 PM	sodium	137.0 mmol/L
LAB-001239	Mon Nov 02, 2026 05:04 PM	hemoglobin	14.44 g/dL
LAB-001243	Mon Nov 02, 2026 05:04 PM	wbc	10.12 x10^3/uL
LAB-001244	Mon Nov 02, 2026 05:04 PM	platelets	261.0 x10^3/uL
LAB-001251	Mon Nov 02, 2026 05:04 PM	bilirubin	0.63 mg/dL
LAB-001232	Tue Nov 03, 2026 05:00 AM	creatinine	1.15 mg/dL
LAB-001236	Tue Nov 03, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-001240	Tue Nov 03, 2026 05:00 AM	hemoglobin	14.44 g/dL
LAB-001245	Tue Nov 03, 2026 05:00 AM	wbc	6.85 x10^3/uL
LAB-001246	Tue Nov 03, 2026 05:00 AM	platelets	239.0 x10^3/uL
LAB-001233	Wed Nov 04, 2026 05:00 AM	creatinine	1.22 mg/dL
LAB-001237	Wed Nov 04, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-001241	Wed Nov 04, 2026 05:00 AM	hemoglobin	14.01 g/dL
LAB-001247	Wed Nov 04, 2026 05:00 AM	wbc	5.8 x10^3/uL
LAB-001248	Wed Nov 04, 2026 05:00 AM	platelets	241.0 x10^3/uL
LAB-001234	Thu Nov 05, 2026 05:00 AM	creatinine	1.2 mg/dL
LAB-001238	Thu Nov 05, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-001242	Thu Nov 05, 2026 05:00 AM	hemoglobin	14.39 g/dL
LAB-001249	Thu Nov 05, 2026 05:00 AM	wbc	10.41 x10^3/uL
LAB-001250	Thu Nov 05, 2026 05:00 AM	platelets	231.0 x10^3/uL

Vitals (54)

Vitals
Row	When	Kind	Value	Detail
VIT-003558	Mon Nov 02, 2026 04:24 PM	spo2	99.0	room air
VIT-003559	Mon Nov 02, 2026 04:24 PM	rr	17.0
VIT-003576	Mon Nov 02, 2026 04:24 PM	temp_c	37.5
VIT-003577	Mon Nov 02, 2026 04:24 PM	hr	74.0
VIT-003578	Mon Nov 02, 2026 04:24 PM	map	81.0
VIT-003579	Mon Nov 02, 2026 04:24 PM	gcs	15.0
VIT-003560	Tue Nov 03, 2026 12:24 AM	spo2	96.0	room air
VIT-003561	Tue Nov 03, 2026 12:24 AM	rr	16.0
VIT-003580	Tue Nov 03, 2026 12:24 AM	temp_c	37.2
VIT-003581	Tue Nov 03, 2026 12:24 AM	hr	89.0
VIT-003582	Tue Nov 03, 2026 12:24 AM	map	88.0
VIT-003583	Tue Nov 03, 2026 12:24 AM	gcs	15.0
VIT-003562	Tue Nov 03, 2026 08:24 AM	spo2	96.0	room air
VIT-003563	Tue Nov 03, 2026 08:24 AM	rr	15.0
VIT-003584	Tue Nov 03, 2026 08:24 AM	temp_c	36.7
VIT-003585	Tue Nov 03, 2026 08:24 AM	hr	71.0
VIT-003586	Tue Nov 03, 2026 08:24 AM	map	90.0
VIT-003587	Tue Nov 03, 2026 08:24 AM	gcs	15.0
VIT-003564	Tue Nov 03, 2026 04:24 PM	spo2	99.0	room air
VIT-003565	Tue Nov 03, 2026 04:24 PM	rr	18.0
VIT-003588	Tue Nov 03, 2026 04:24 PM	temp_c	37.2
VIT-003589	Tue Nov 03, 2026 04:24 PM	hr	74.0
VIT-003590	Tue Nov 03, 2026 04:24 PM	map	77.0
VIT-003591	Tue Nov 03, 2026 04:24 PM	gcs	15.0
VIT-003566	Wed Nov 04, 2026 12:24 AM	spo2	99.0	room air
VIT-003567	Wed Nov 04, 2026 12:24 AM	rr	18.0
VIT-003592	Wed Nov 04, 2026 12:24 AM	temp_c	37.0
VIT-003593	Wed Nov 04, 2026 12:24 AM	hr	78.0
VIT-003594	Wed Nov 04, 2026 12:24 AM	map	91.0
VIT-003595	Wed Nov 04, 2026 12:24 AM	gcs	15.0
VIT-003568	Wed Nov 04, 2026 08:24 AM	spo2	97.0	room air
VIT-003569	Wed Nov 04, 2026 08:24 AM	rr	20.0
VIT-003596	Wed Nov 04, 2026 08:24 AM	temp_c	37.0
VIT-003597	Wed Nov 04, 2026 08:24 AM	hr	86.0
VIT-003598	Wed Nov 04, 2026 08:24 AM	map	83.0
VIT-003599	Wed Nov 04, 2026 08:24 AM	gcs	15.0
VIT-003570	Wed Nov 04, 2026 04:24 PM	spo2	95.0	room air
VIT-003571	Wed Nov 04, 2026 04:24 PM	rr	20.0
VIT-003600	Wed Nov 04, 2026 04:24 PM	temp_c	37.4
VIT-003601	Wed Nov 04, 2026 04:24 PM	hr	81.0
VIT-003602	Wed Nov 04, 2026 04:24 PM	map	86.0
VIT-003603	Wed Nov 04, 2026 04:24 PM	gcs	15.0
VIT-003572	Thu Nov 05, 2026 12:24 AM	spo2	95.0	room air
VIT-003573	Thu Nov 05, 2026 12:24 AM	rr	20.0
VIT-003604	Thu Nov 05, 2026 12:24 AM	temp_c	36.8
VIT-003605	Thu Nov 05, 2026 12:24 AM	hr	88.0
VIT-003606	Thu Nov 05, 2026 12:24 AM	map	81.0
VIT-003607	Thu Nov 05, 2026 12:24 AM	gcs	15.0
VIT-003574	Thu Nov 05, 2026 08:24 AM	spo2	99.0	room air
VIT-003575	Thu Nov 05, 2026 08:24 AM	rr	17.0
VIT-003608	Thu Nov 05, 2026 08:24 AM	temp_c	37.3
VIT-003609	Thu Nov 05, 2026 08:24 AM	hr	75.0
VIT-003610	Thu Nov 05, 2026 08:24 AM	map	87.0
VIT-003611	Thu Nov 05, 2026 08:24 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000128 11-02 17:04 cefepime per protocol IV
MED-000129 11-03 05:00 ceftriaxone per protocol IV
MED-000130 11-04 05:00 cefepime per protocol IV
ORD-000030 11-02 16:34 blood_culture: blood cultures x2

Notes

History and physical · DOC-000119 · Dr. Priya Thorne (resident) · Mon Nov 02, 2026 07:04 PM

Cited facts from this note (1)

infection_source: right lower lobe pneumonia · cited p. 1, line 5 · confidence 0.85

Show source for infection_source

… Hospital Medicine Attending: Dr. Wes Merriweather History of present illness: 70-year-old man admitted with community-acquired pneumonia. Chest x-ray shows right lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: hypertension. Review of systems otherwise negative. Exam: Lungs: clear to auscultation bil …

Source document DOC-000119: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Odette Penhallow   MRN: MRN60628496   Admitted: 2026-11-02 16:04
Service: Hospital Medicine   Attending: Dr. Wes Merriweather

History of present illness: 70-year-old man admitted with community-acquired pneumonia. Chest x-ray shows right lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: hypertension.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Progress note · DOC-000120 · Dr. Priya Thorne (resident) · Wed Nov 04, 2026 04:04 PM

Source document DOC-000120: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Odette Penhallow   MRN: MRN60628496   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Community-acquired pneumonia: continue current management.

Resident: Dr. Priya Thorne   Attending cosign: completed

Discharge summary · DOC-000121 · Dr. Wes Merriweather (attending) · Thu Nov 05, 2026 01:26 PM

Source document DOC-000121: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Odette Penhallow   MRN: MRN60628496
Admitted 2026-11-02; discharged 2026-11-05.

Discharge diagnoses:
- community-acquired pneumonia
- hypertension

Disposition: home with follow-up.