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-00046: Kenji Galloway

65M · MRN99700670 · Hospital Medicine · admitted Sun Nov 01, 2026 04:01 PM · discharged Mon Nov 09, 2026 03:39 PM · attending Dr. Jalen Carrow · 163 cm, 56.7 kg

Documented diagnoses (current)

Principal: “urinary tract infection” · N39.0 Urinary tract infection, site not specified
“acute hypoxic respiratory failure” · J96.01 Acute respiratory failure with hypoxia
“acute blood loss anemia” · D62 Acute posthemorrhagic anemia
“type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications

Illustrative grouping now: MS-DRG 689 Kidney and urinary tract infections 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 met

Specificity gap

Criteria support Acute kidney injury (KDIGO stage 1) (N17.9); no corresponding diagnosis is documented.

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=1.667, t.ratio_s1=1.5, creat_rise_48h=0.34, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, t.uo_s1_h=6	true
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=True, creat_ratio=1.667, t.ratio_s3=3.0, creat_peak=1.55, 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=1.667, 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=True	1
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=0.34, t.rise_abs=0.3, rrt_started=False	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	stage=1, baseline_independent=True	true

Acute blood loss anaemia

Criteria met

Clinical validation gap

Documented “acute blood loss anemia” (D62) is more specific than the criteria support (Anemia (acute blood-loss criteria not met), D64.9).

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=11.11, t.hb_m=13, t.hb_f=12	true
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=True, anaemic=True, acute_fall=False	false
outcome: anaemia_only	`anaemic and hgb_drop < t.drop_min and prbc_units == 0`	anaemic=True, hgb_drop=0.4, t.drop_min=1.0, prbc_units=0	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=309, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=88.8, egfr_late=91.1	91.1
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=88.8, t.g2=60, egfr_late=91.1	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=91.1, 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=88.8, egfr_late=91.1, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=91.1, t.g2=60	true

Heart failure

Clinical judgement required

No gap

Not documented; only one acute indicator; acuity needs clinical judgement.

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=True	1
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=1, 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=1	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=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

Criteria met

Specificity gap

Criteria support Severe protein-calorie malnutrition (acute illness context) (E43); no corresponding diagnosis is documented.

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=50.0, t.a_sev_intake_pct=50, intake_days=8.0, t.a_sev_intake_days=5	true
derived: a_mod_intake	`intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days`	intake_pct=50.0, t.a_mod_intake_pct=75, intake_days=8.0, t.a_mod_intake_days=7	true
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=30.0, wt_loss_pct=6.6	true
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=30.0, wt_loss_pct=6.6	true
derived: c_sev_intake	`intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=50.0, t.c_intake_pct=75, intake_days=8.0, 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=50.0, t.c_intake_pct=75, intake_days=8.0, 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=30.0, wt_loss_pct=6.6	true
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=30.0, wt_loss_pct=6.6	true
derived: n_assessed	`known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced)`	intake_pct=50.0, wt_loss_pct=6.6, fat_loss=2, muscle_loss=2, fluid=0, grip_reduced=True	6
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=True, a_sev_wt=True, fat_loss=2, muscle_loss=2, fluid=0, grip_reduced=True, c_sev_intake=False, c_sev_wt=True	5
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=True, a_mod_intake=True, a_sev_wt=True, a_mod_wt=True, fat_loss=2, muscle_loss=2, fluid=0, grip_reduced=True, c_sev_intake=False, c_mod_intake=False, c_sev_wt=True, c_mod_wt=True	5
outcome: severe	`n_severe >= 2`	n_severe=5	true

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=65, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=21.3, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=21.3, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=21.3, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=21.3, 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 met

No gap

Supported as documented (J96.01).

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=84.0, pao2_min_ra=50.0, pf_min=238	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=84.0, t.spo2_ra=88, pao2_min_ra=50.0, t.pao2=60, pf_min=238, t.pf=300	true
derived: distress	`coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support`	rr_max=33.0, t.rr_distress=28, wob_increased=True, adv_resp_support=False	true
outcome: chronic_baseline	`home_o2 and hypoxemia`	home_o2=False, hypoxemia=True	false
outcome: met	`hypoxemia and distress`	hypoxemia=True, distress=True	true

Sepsis

Criteria met

No gap

Criteria support Sepsis (Sepsis-3); not documented (this rule does not prompt for an undocumented diagnosis).

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=36.8, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=83.0, 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=33.0, t.rr=20, paco2_min_48h=unknown, t.paco2=32	true
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=10.37, t.wbc_hi=12, wbc_min_48h=9.51, 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=True, sirs_wbc=False	1
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=238, adv_resp_support=False	2
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=189.0	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=0.41	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=74.0	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=1.55	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=0.93	0
derived: sofa_delta	`sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline`	sofa_resp=2, sofa_coag=0, sofa_liver=0, sofa_cardio=0, sofa_cns=0, sofa_renal=1, sofa_renal_baseline=0	3
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=3, t.sofa_delta=2	true
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=True, sirs_count=1, t.sirs_min=2	false
derived: shock	`sepsis3 and norepi_max_48h > 0 and coalesce(lactate_max_48h > t.lactate, false)`	sepsis3=True, 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=True, sepsis2=False	false
outcome: sepsis3_only	`sepsis3`	sepsis3=True	true

Structured data

Labs (50)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-001570	Tue Oct 28, 2025 09:15 AM	creatinine	0.95 mg/dL
LAB-001571	Wed Sep 02, 2026 10:05 AM	creatinine	0.93 mg/dL
LAB-001581	Sun Nov 01, 2026 04:26 PM	pao2	50.0 mmHg
LAB-001582	Sun Nov 01, 2026 04:26 PM	fio2	21.0 %
LAB-001572	Sun Nov 01, 2026 05:01 PM	creatinine	1.21 mg/dL
LAB-001583	Sun Nov 01, 2026 05:01 PM	sodium	136.0 mmol/L
LAB-001592	Sun Nov 01, 2026 05:01 PM	hemoglobin	11.51 g/dL
LAB-001601	Sun Nov 01, 2026 05:01 PM	wbc	10.29 x10^3/uL
LAB-001602	Sun Nov 01, 2026 05:01 PM	platelets	209.0 x10^3/uL
LAB-001619	Sun Nov 01, 2026 05:01 PM	bilirubin	0.41 mg/dL
LAB-001573	Mon Nov 02, 2026 05:00 AM	creatinine	1.55 mg/dL
LAB-001584	Mon Nov 02, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-001593	Mon Nov 02, 2026 05:00 AM	hemoglobin	11.11 g/dL
LAB-001603	Mon Nov 02, 2026 05:00 AM	wbc	10.37 x10^3/uL
LAB-001604	Mon Nov 02, 2026 05:00 AM	platelets	189.0 x10^3/uL
LAB-001574	Tue Nov 03, 2026 05:00 AM	creatinine	1.39 mg/dL
LAB-001585	Tue Nov 03, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-001594	Tue Nov 03, 2026 05:00 AM	hemoglobin	11.51 g/dL
LAB-001605	Tue Nov 03, 2026 05:00 AM	wbc	9.51 x10^3/uL
LAB-001606	Tue Nov 03, 2026 05:00 AM	platelets	294.0 x10^3/uL
LAB-001575	Wed Nov 04, 2026 05:00 AM	creatinine	1.16 mg/dL
LAB-001586	Wed Nov 04, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-001595	Wed Nov 04, 2026 05:00 AM	hemoglobin	11.11 g/dL
LAB-001607	Wed Nov 04, 2026 05:00 AM	wbc	10.43 x10^3/uL
LAB-001608	Wed Nov 04, 2026 05:00 AM	platelets	294.0 x10^3/uL
LAB-001576	Thu Nov 05, 2026 05:00 AM	creatinine	0.98 mg/dL
LAB-001587	Thu Nov 05, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-001596	Thu Nov 05, 2026 05:00 AM	hemoglobin	11.51 g/dL
LAB-001609	Thu Nov 05, 2026 05:00 AM	wbc	6.71 x10^3/uL
LAB-001610	Thu Nov 05, 2026 05:00 AM	platelets	263.0 x10^3/uL
LAB-001577	Fri Nov 06, 2026 05:00 AM	creatinine	0.98 mg/dL
LAB-001588	Fri Nov 06, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-001597	Fri Nov 06, 2026 05:00 AM	hemoglobin	11.11 g/dL
LAB-001611	Fri Nov 06, 2026 05:00 AM	wbc	9.45 x10^3/uL
LAB-001612	Fri Nov 06, 2026 05:00 AM	platelets	247.0 x10^3/uL
LAB-001578	Sat Nov 07, 2026 05:00 AM	creatinine	0.98 mg/dL
LAB-001589	Sat Nov 07, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-001598	Sat Nov 07, 2026 05:00 AM	hemoglobin	11.51 g/dL
LAB-001613	Sat Nov 07, 2026 05:00 AM	wbc	9.16 x10^3/uL
LAB-001614	Sat Nov 07, 2026 05:00 AM	platelets	296.0 x10^3/uL
LAB-001579	Sun Nov 08, 2026 05:00 AM	creatinine	0.98 mg/dL
LAB-001590	Sun Nov 08, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-001599	Sun Nov 08, 2026 05:00 AM	hemoglobin	11.11 g/dL
LAB-001615	Sun Nov 08, 2026 05:00 AM	wbc	8.02 x10^3/uL
LAB-001616	Sun Nov 08, 2026 05:00 AM	platelets	291.0 x10^3/uL
LAB-001580	Mon Nov 09, 2026 05:00 AM	creatinine	0.98 mg/dL
LAB-001591	Mon Nov 09, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-001600	Mon Nov 09, 2026 05:00 AM	hemoglobin	11.51 g/dL
LAB-001617	Mon Nov 09, 2026 05:00 AM	wbc	9.47 x10^3/uL
LAB-001618	Mon Nov 09, 2026 05:00 AM	platelets	289.0 x10^3/uL

Vitals (168)

Vitals
Row	When	Kind	Value	Detail
VIT-004543	Sun Nov 01, 2026 04:21 PM	spo2	84.0	room air
VIT-004544	Sun Nov 01, 2026 04:21 PM	rr	33.0
VIT-004615	Sun Nov 01, 2026 04:21 PM	temp_c	37.3
VIT-004616	Sun Nov 01, 2026 04:21 PM	hr	83.0
VIT-004617	Sun Nov 01, 2026 04:21 PM	map	78.0
VIT-004618	Sun Nov 01, 2026 04:21 PM	gcs	15.0
VIT-004545	Sun Nov 01, 2026 04:31 PM	o2_lpm	6.0	nasal cannula
VIT-004546	Mon Nov 02, 2026 12:21 AM	spo2	93.0	nasal cannula
VIT-004547	Mon Nov 02, 2026 12:21 AM	rr	23.0
VIT-004548	Mon Nov 02, 2026 12:21 AM	o2_lpm	4.0	nasal cannula
VIT-004619	Mon Nov 02, 2026 12:21 AM	temp_c	37.4
VIT-004620	Mon Nov 02, 2026 12:21 AM	hr	83.0
VIT-004621	Mon Nov 02, 2026 12:21 AM	map	78.0
VIT-004622	Mon Nov 02, 2026 12:21 AM	gcs	15.0
VIT-004549	Mon Nov 02, 2026 08:21 AM	spo2	93.0	nasal cannula
VIT-004550	Mon Nov 02, 2026 08:21 AM	rr	23.0
VIT-004551	Mon Nov 02, 2026 08:21 AM	o2_lpm	4.0	nasal cannula
VIT-004623	Mon Nov 02, 2026 08:21 AM	temp_c	36.8
VIT-004624	Mon Nov 02, 2026 08:21 AM	hr	71.0
VIT-004625	Mon Nov 02, 2026 08:21 AM	map	86.0
VIT-004626	Mon Nov 02, 2026 08:21 AM	gcs	15.0
VIT-004552	Mon Nov 02, 2026 04:21 PM	spo2	94.0	nasal cannula
VIT-004553	Mon Nov 02, 2026 04:21 PM	rr	23.0
VIT-004554	Mon Nov 02, 2026 04:21 PM	o2_lpm	2.0	nasal cannula
VIT-004627	Mon Nov 02, 2026 04:21 PM	temp_c	37.0
VIT-004628	Mon Nov 02, 2026 04:21 PM	hr	74.0
VIT-004629	Mon Nov 02, 2026 04:21 PM	map	80.0
VIT-004630	Mon Nov 02, 2026 04:21 PM	gcs	15.0
VIT-004555	Tue Nov 03, 2026 12:21 AM	spo2	92.0	nasal cannula
VIT-004556	Tue Nov 03, 2026 12:21 AM	rr	24.0
VIT-004557	Tue Nov 03, 2026 12:21 AM	o2_lpm	3.0	nasal cannula
VIT-004631	Tue Nov 03, 2026 12:21 AM	temp_c	37.4
VIT-004632	Tue Nov 03, 2026 12:21 AM	hr	83.0
VIT-004633	Tue Nov 03, 2026 12:21 AM	map	74.0
VIT-004634	Tue Nov 03, 2026 12:21 AM	gcs	15.0
VIT-004558	Tue Nov 03, 2026 08:21 AM	spo2	94.0	nasal cannula
VIT-004559	Tue Nov 03, 2026 08:21 AM	rr	21.0
VIT-004560	Tue Nov 03, 2026 08:21 AM	o2_lpm	3.0	nasal cannula
VIT-004635	Tue Nov 03, 2026 08:21 AM	temp_c	37.6
VIT-004636	Tue Nov 03, 2026 08:21 AM	hr	81.0
VIT-004637	Tue Nov 03, 2026 08:21 AM	map	83.0
VIT-004638	Tue Nov 03, 2026 08:21 AM	gcs	15.0
VIT-004561	Tue Nov 03, 2026 04:21 PM	spo2	91.0	nasal cannula
VIT-004562	Tue Nov 03, 2026 04:21 PM	rr	25.0
VIT-004563	Tue Nov 03, 2026 04:21 PM	o2_lpm	2.0	nasal cannula
VIT-004639	Tue Nov 03, 2026 04:21 PM	temp_c	37.6
VIT-004640	Tue Nov 03, 2026 04:21 PM	hr	68.0
VIT-004641	Tue Nov 03, 2026 04:21 PM	map	84.0
VIT-004642	Tue Nov 03, 2026 04:21 PM	gcs	15.0
VIT-004564	Wed Nov 04, 2026 12:21 AM	spo2	93.0	nasal cannula
VIT-004565	Wed Nov 04, 2026 12:21 AM	rr	21.0
VIT-004566	Wed Nov 04, 2026 12:21 AM	o2_lpm	4.0	nasal cannula
VIT-004643	Wed Nov 04, 2026 12:21 AM	temp_c	36.7
VIT-004644	Wed Nov 04, 2026 12:21 AM	hr	71.0
VIT-004645	Wed Nov 04, 2026 12:21 AM	map	74.0
VIT-004646	Wed Nov 04, 2026 12:21 AM	gcs	15.0
VIT-004567	Wed Nov 04, 2026 08:21 AM	spo2	91.0	nasal cannula
VIT-004568	Wed Nov 04, 2026 08:21 AM	rr	20.0
VIT-004569	Wed Nov 04, 2026 08:21 AM	o2_lpm	3.0	nasal cannula
VIT-004647	Wed Nov 04, 2026 08:21 AM	temp_c	37.2
VIT-004648	Wed Nov 04, 2026 08:21 AM	hr	81.0
VIT-004649	Wed Nov 04, 2026 08:21 AM	map	82.0
VIT-004650	Wed Nov 04, 2026 08:21 AM	gcs	15.0
VIT-004570	Wed Nov 04, 2026 04:21 PM	spo2	94.0	nasal cannula
VIT-004571	Wed Nov 04, 2026 04:21 PM	rr	23.0
VIT-004572	Wed Nov 04, 2026 04:21 PM	o2_lpm	3.0	nasal cannula
VIT-004651	Wed Nov 04, 2026 04:21 PM	temp_c	37.2
VIT-004652	Wed Nov 04, 2026 04:21 PM	hr	74.0
VIT-004653	Wed Nov 04, 2026 04:21 PM	map	83.0
VIT-004654	Wed Nov 04, 2026 04:21 PM	gcs	15.0
VIT-004573	Thu Nov 05, 2026 12:21 AM	spo2	95.0	nasal cannula
VIT-004574	Thu Nov 05, 2026 12:21 AM	rr	22.0
VIT-004575	Thu Nov 05, 2026 12:21 AM	o2_lpm	3.0	nasal cannula
VIT-004655	Thu Nov 05, 2026 12:21 AM	temp_c	36.6
VIT-004656	Thu Nov 05, 2026 12:21 AM	hr	80.0
VIT-004657	Thu Nov 05, 2026 12:21 AM	map	84.0
VIT-004658	Thu Nov 05, 2026 12:21 AM	gcs	15.0
VIT-004576	Thu Nov 05, 2026 08:21 AM	spo2	91.0	nasal cannula
VIT-004577	Thu Nov 05, 2026 08:21 AM	rr	21.0
VIT-004578	Thu Nov 05, 2026 08:21 AM	o2_lpm	4.0	nasal cannula
VIT-004659	Thu Nov 05, 2026 08:21 AM	temp_c	37.2
VIT-004660	Thu Nov 05, 2026 08:21 AM	hr	92.0
VIT-004661	Thu Nov 05, 2026 08:21 AM	map	86.0
VIT-004662	Thu Nov 05, 2026 08:21 AM	gcs	15.0
VIT-004579	Thu Nov 05, 2026 04:21 PM	spo2	93.0	nasal cannula
VIT-004580	Thu Nov 05, 2026 04:21 PM	rr	21.0
VIT-004581	Thu Nov 05, 2026 04:21 PM	o2_lpm	2.0	nasal cannula
VIT-004663	Thu Nov 05, 2026 04:21 PM	temp_c	36.7
VIT-004664	Thu Nov 05, 2026 04:21 PM	hr	85.0
VIT-004665	Thu Nov 05, 2026 04:21 PM	map	86.0
VIT-004666	Thu Nov 05, 2026 04:21 PM	gcs	15.0
VIT-004582	Fri Nov 06, 2026 12:21 AM	spo2	91.0	nasal cannula
VIT-004583	Fri Nov 06, 2026 12:21 AM	rr	21.0
VIT-004584	Fri Nov 06, 2026 12:21 AM	o2_lpm	3.0	nasal cannula
VIT-004667	Fri Nov 06, 2026 12:21 AM	temp_c	36.6
VIT-004668	Fri Nov 06, 2026 12:21 AM	hr	84.0
VIT-004669	Fri Nov 06, 2026 12:21 AM	map	83.0
VIT-004670	Fri Nov 06, 2026 12:21 AM	gcs	15.0
VIT-004585	Fri Nov 06, 2026 08:21 AM	spo2	95.0	nasal cannula
VIT-004586	Fri Nov 06, 2026 08:21 AM	rr	20.0
VIT-004587	Fri Nov 06, 2026 08:21 AM	o2_lpm	3.0	nasal cannula
VIT-004671	Fri Nov 06, 2026 08:21 AM	temp_c	36.7
VIT-004672	Fri Nov 06, 2026 08:21 AM	hr	73.0
VIT-004673	Fri Nov 06, 2026 08:21 AM	map	82.0
VIT-004674	Fri Nov 06, 2026 08:21 AM	gcs	15.0
VIT-004588	Fri Nov 06, 2026 04:21 PM	spo2	91.0	nasal cannula
VIT-004589	Fri Nov 06, 2026 04:21 PM	rr	23.0
VIT-004590	Fri Nov 06, 2026 04:21 PM	o2_lpm	2.0	nasal cannula
VIT-004675	Fri Nov 06, 2026 04:21 PM	temp_c	37.6
VIT-004676	Fri Nov 06, 2026 04:21 PM	hr	90.0
VIT-004677	Fri Nov 06, 2026 04:21 PM	map	74.0
VIT-004678	Fri Nov 06, 2026 04:21 PM	gcs	15.0
VIT-004591	Sat Nov 07, 2026 12:21 AM	spo2	91.0	nasal cannula
VIT-004592	Sat Nov 07, 2026 12:21 AM	rr	20.0
VIT-004593	Sat Nov 07, 2026 12:21 AM	o2_lpm	3.0	nasal cannula
VIT-004679	Sat Nov 07, 2026 12:21 AM	temp_c	36.6
VIT-004680	Sat Nov 07, 2026 12:21 AM	hr	92.0
VIT-004681	Sat Nov 07, 2026 12:21 AM	map	84.0
VIT-004682	Sat Nov 07, 2026 12:21 AM	gcs	15.0
VIT-004594	Sat Nov 07, 2026 08:21 AM	spo2	95.0	nasal cannula
VIT-004595	Sat Nov 07, 2026 08:21 AM	rr	20.0
VIT-004596	Sat Nov 07, 2026 08:21 AM	o2_lpm	3.0	nasal cannula
VIT-004683	Sat Nov 07, 2026 08:21 AM	temp_c	36.7
VIT-004684	Sat Nov 07, 2026 08:21 AM	hr	78.0
VIT-004685	Sat Nov 07, 2026 08:21 AM	map	75.0
VIT-004686	Sat Nov 07, 2026 08:21 AM	gcs	15.0
VIT-004597	Sat Nov 07, 2026 04:21 PM	spo2	93.0	nasal cannula
VIT-004598	Sat Nov 07, 2026 04:21 PM	rr	25.0
VIT-004599	Sat Nov 07, 2026 04:21 PM	o2_lpm	4.0	nasal cannula
VIT-004687	Sat Nov 07, 2026 04:21 PM	temp_c	37.1
VIT-004688	Sat Nov 07, 2026 04:21 PM	hr	88.0
VIT-004689	Sat Nov 07, 2026 04:21 PM	map	74.0
VIT-004690	Sat Nov 07, 2026 04:21 PM	gcs	15.0
VIT-004600	Sun Nov 08, 2026 12:21 AM	spo2	95.0	nasal cannula
VIT-004601	Sun Nov 08, 2026 12:21 AM	rr	21.0
VIT-004602	Sun Nov 08, 2026 12:21 AM	o2_lpm	4.0	nasal cannula
VIT-004691	Sun Nov 08, 2026 12:21 AM	temp_c	37.3
VIT-004692	Sun Nov 08, 2026 12:21 AM	hr	74.0
VIT-004693	Sun Nov 08, 2026 12:21 AM	map	81.0
VIT-004694	Sun Nov 08, 2026 12:21 AM	gcs	15.0
VIT-004603	Sun Nov 08, 2026 08:21 AM	spo2	94.0	nasal cannula
VIT-004604	Sun Nov 08, 2026 08:21 AM	rr	21.0
VIT-004605	Sun Nov 08, 2026 08:21 AM	o2_lpm	3.0	nasal cannula
VIT-004695	Sun Nov 08, 2026 08:21 AM	temp_c	36.8
VIT-004696	Sun Nov 08, 2026 08:21 AM	hr	75.0
VIT-004697	Sun Nov 08, 2026 08:21 AM	map	78.0
VIT-004698	Sun Nov 08, 2026 08:21 AM	gcs	15.0
VIT-004606	Sun Nov 08, 2026 04:21 PM	spo2	95.0	nasal cannula
VIT-004607	Sun Nov 08, 2026 04:21 PM	rr	24.0
VIT-004608	Sun Nov 08, 2026 04:21 PM	o2_lpm	3.0	nasal cannula
VIT-004699	Sun Nov 08, 2026 04:21 PM	temp_c	36.9
VIT-004700	Sun Nov 08, 2026 04:21 PM	hr	85.0
VIT-004701	Sun Nov 08, 2026 04:21 PM	map	75.0
VIT-004702	Sun Nov 08, 2026 04:21 PM	gcs	15.0
VIT-004609	Mon Nov 09, 2026 12:21 AM	spo2	93.0	nasal cannula
VIT-004610	Mon Nov 09, 2026 12:21 AM	rr	22.0
VIT-004611	Mon Nov 09, 2026 12:21 AM	o2_lpm	2.0	nasal cannula
VIT-004703	Mon Nov 09, 2026 12:21 AM	temp_c	36.5
VIT-004704	Mon Nov 09, 2026 12:21 AM	hr	86.0
VIT-004705	Mon Nov 09, 2026 12:21 AM	map	90.0
VIT-004706	Mon Nov 09, 2026 12:21 AM	gcs	15.0
VIT-004612	Mon Nov 09, 2026 08:21 AM	spo2	94.0	nasal cannula
VIT-004613	Mon Nov 09, 2026 08:21 AM	rr	22.0
VIT-004614	Mon Nov 09, 2026 08:21 AM	o2_lpm	4.0	nasal cannula
VIT-004707	Mon Nov 09, 2026 08:21 AM	temp_c	37.5
VIT-004708	Mon Nov 09, 2026 08:21 AM	hr	85.0
VIT-004709	Mon Nov 09, 2026 08:21 AM	map	79.0
VIT-004710	Mon Nov 09, 2026 08:21 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000167 11-01 17:01 piperacillin-tazobactam per protocol IV
MED-000168 11-02 05:00 ceftriaxone per protocol IV
MED-000169 11-03 05:00 piperacillin-tazobactam per protocol IV
ORD-000038 11-01 16:31 blood_culture: blood cultures x2

Notes

History and physical · DOC-000159 · Dr. Jalen Carrow (attending) · Sun Nov 01, 2026 07:01 PM

Cited facts from this note (3)

bleeding_source: bleeding · cited p. 1, line 7 · confidence 0.50

Show source for bleeding_source

… admitted with urinary tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime. Past medical history: type 2 diabetes. Denies bleeding, chest pain or fever. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. Urinary tract infection: antibiotics.
infection_source: urinary tract infection · cited p. 1, line 5 · confidence 0.85

Show source for infection_source

… N: MRN99700670 Admitted: 2026-11-01 16:01 Service: Hospital Medicine Attending: Dr. Jalen Carrow History of present illness: 65-year-old man admitted with urinary tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime. Past medical history: type 2 diabetes. Denies bleeding, chest pain or fever. Exam: …
work_of_breathing: increased · cited p. 1, line 8 · confidence 0.90

Show source for work_of_breathing

… lysis with pyuria; treated for urinary tract infection with cefepime. Past medical history: type 2 diabetes. Denies bleeding, chest pain or fever. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. Urinary tract infection: antibiotics.

Source document DOC-000159: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Kenji Galloway   MRN: MRN99700670   Admitted: 2026-11-01 16:01
Service: Hospital Medicine   Attending: Dr. Jalen Carrow

History of present illness: 65-year-old man admitted with urinary tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime.
Past medical history: type 2 diabetes.
Denies bleeding, chest pain or fever.
Exam: Lungs: increased work of breathing with accessory muscle use.
Assessment and plan:
1. Urinary tract infection: antibiotics.

Nutrition assessment · DOC-000158 · Dario Larkspur, RD (dietitian) · Mon Nov 02, 2026 09:01 PM

Cited facts from this note (9)

fat_loss: moderate · cited p. 1, line 7 · confidence 0.90

Show source for fat_loss

… Context: acute illness Intake: estimated energy intake 50% of needs for 8 days. Weight history: 6.6% weight loss over 30 days. Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation. Grip strength: reduced per dynamometry. Recommendations: high-protein oral supplement; calorie counts; weekly …
fluid_accumulation: none · cited p. 1, line 7 · confidence 0.90

Show source for fluid_accumulation

… f needs for 8 days. Weight history: 6.6% weight loss over 30 days. Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation. Grip strength: reduced per dynamometry. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
grip_strength: reduced · cited p. 1, line 8 · confidence 0.90

Show source for grip_strength

… ght history: 6.6% weight loss over 30 days. Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation. Grip strength: reduced per dynamometry. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
intake_days: 8 · cited p. 1, line 5 · confidence 0.95

Show source for intake_days

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Kenji Galloway MRN: MRN99700670 Context: acute illness Intake: estimated energy intake 50% of needs for 8 days. Weight history: 6.6% weight loss over 30 days. Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulat …
intake_pct: 50 · cited p. 1, line 5 · confidence 0.95

Show source for intake_pct

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Kenji Galloway MRN: MRN99700670 Context: acute illness Intake: estimated energy intake 50% of needs for 8 days. Weight history: 6.6% weight loss over 30 days. Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulat …
muscle_loss: moderate · cited p. 1, line 7 · confidence 0.90

Show source for muscle_loss

… mated energy intake 50% of needs for 8 days. Weight history: 6.6% weight loss over 30 days. Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation. Grip strength: reduced per dynamometry. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
nutrition_context: acute · cited p. 1, line 4 · confidence 0.95

Show source for nutrition_context

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Kenji Galloway MRN: MRN99700670 Context: acute illness Intake: estimated energy intake 50% of needs for 8 days. Weight history: 6.6% weight loss over 30 days. Nutrition-focused physical exam: moderate loss of subcu …
weight_loss_days: 30 · cited p. 1, line 6 · confidence 0.95

Show source for weight_loss_days

… gistered Dietitian) Patient: Kenji Galloway MRN: MRN99700670 Context: acute illness Intake: estimated energy intake 50% of needs for 8 days. Weight history: 6.6% weight loss over 30 days. Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation. Grip strength: reduced per dynamometry. Re …
weight_loss_pct: 6.6 · cited p. 1, line 6 · confidence 0.95

Show source for weight_loss_pct

… gistered Dietitian) Patient: Kenji Galloway MRN: MRN99700670 Context: acute illness Intake: estimated energy intake 50% of needs for 8 days. Weight history: 6.6% weight loss over 30 days. Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation. Grip strength: reduced per dynamometry. Re …

Source document DOC-000158: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Kenji Galloway   MRN: MRN99700670

Context: acute illness
Intake: estimated energy intake 50% of needs for 8 days.
Weight history: 6.6% weight loss over 30 days.
Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation.
Grip strength: reduced per dynamometry.
Recommendations: high-protein oral supplement; calorie counts; weekly weights.

Progress note · DOC-000160 · Dr. Jalen Carrow (attending) · Tue Nov 03, 2026 04:01 PM

Source document DOC-000160: Progress note (synthetic)

PROGRESS NOTE (Attending)
Patient: Kenji Galloway   MRN: MRN99700670   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Urinary tract infection: continue current management.
2. Acute hypoxic respiratory failure: supplemental oxygen, wean as tolerated.
3. Acute blood loss anemia: trend hemoglobin, transfuse if needed.

Attending: Dr. Jalen Carrow

Discharge summary · DOC-000161 · Dr. Jalen Carrow (attending) · Mon Nov 09, 2026 03:39 PM

Source document DOC-000161: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Kenji Galloway   MRN: MRN99700670
Admitted 2026-11-01; discharged 2026-11-09.

Discharge diagnoses:
- urinary tract infection
- acute hypoxic respiratory failure
- acute blood loss anemia
- type 2 diabetes

Disposition: home with follow-up.