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-00047: Gideon Pemberton

52F · MRN92060182 · Pulmonology · admitted Sat Nov 07, 2026 09:10 PM · discharged Tue Nov 10, 2026 12:50 PM · attending Dr. Isaac Abernath · 154 cm, 48.9 kg

Documented diagnoses (current)

Principal: “COPD exacerbation” · J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
“GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis
“type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications

Illustrative grouping now: MS-DRG 192 Chronic obstructive pulmonary disease without CC/MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 191.

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=1.0, t.ratio_s1=1.5, creat_rise_48h=0.0, 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=1.0, t.ratio_s3=3.0, creat_peak=0.87, 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=1.0, 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=0.0, 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=13.74, 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=13.74, 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=334, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=83.6, egfr_late=80.1	83.6
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=83.6, t.g2=60, egfr_late=80.1	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=83.6, 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=83.6, egfr_late=80.1, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=83.6, 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=137.0, 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=137.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=137.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=137.0, t.low=135	true

Malnutrition

Criteria met

Specificity gap

Criteria support Moderate (non-severe) protein-calorie malnutrition (acute illness context) (E44.0); 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=70.0, t.a_sev_intake_pct=50, intake_days=9.0, 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=70.0, t.a_mod_intake_pct=75, intake_days=9.0, 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=5.1	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=5.1	true
derived: c_sev_intake	`intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=70.0, t.c_intake_pct=75, intake_days=9.0, 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=70.0, t.c_intake_pct=75, intake_days=9.0, 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=5.1	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=5.1	true
derived: n_assessed	`known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced)`	intake_pct=70.0, wt_loss_pct=5.1, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown	5
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=True, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_sev_wt=True	1
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=True, a_sev_wt=True, a_mod_wt=True, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_mod_intake=False, c_sev_wt=True, c_mod_wt=True	4
outcome: severe	`n_severe >= 2`	n_severe=1	false
outcome: moderate	`n_moderate >= 2`	n_moderate=4	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=52, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=20.6, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=20.6, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=20.6, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=20.6, 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

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=36.5, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=90.0, 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=10.42, t.wbc_hi=12, wbc_min_48h=6.28, 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=233.0	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=0.57	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=0.87	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=0.87	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=False, sofa_delta=0, t.sofa_delta=2	false
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=False, 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=False	true

Structured data

Labs (23)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-001620	Wed Nov 05, 2025 09:15 AM	creatinine	0.84 mg/dL
LAB-001621	Tue Oct 06, 2026 10:05 AM	creatinine	0.87 mg/dL
LAB-001622	Sat Nov 07, 2026 10:10 PM	creatinine	0.87 mg/dL
LAB-001626	Sat Nov 07, 2026 10:10 PM	sodium	138.0 mmol/L
LAB-001630	Sat Nov 07, 2026 10:10 PM	hemoglobin	13.74 g/dL
LAB-001634	Sat Nov 07, 2026 10:10 PM	wbc	6.73 x10^3/uL
LAB-001635	Sat Nov 07, 2026 10:10 PM	platelets	233.0 x10^3/uL
LAB-001642	Sat Nov 07, 2026 10:10 PM	bilirubin	0.57 mg/dL
LAB-001623	Sun Nov 08, 2026 05:00 AM	creatinine	0.86 mg/dL
LAB-001627	Sun Nov 08, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-001631	Sun Nov 08, 2026 05:00 AM	hemoglobin	13.89 g/dL
LAB-001636	Sun Nov 08, 2026 05:00 AM	wbc	6.28 x10^3/uL
LAB-001637	Sun Nov 08, 2026 05:00 AM	platelets	277.0 x10^3/uL
LAB-001624	Mon Nov 09, 2026 05:00 AM	creatinine	0.86 mg/dL
LAB-001628	Mon Nov 09, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-001632	Mon Nov 09, 2026 05:00 AM	hemoglobin	14.08 g/dL
LAB-001638	Mon Nov 09, 2026 05:00 AM	wbc	10.42 x10^3/uL
LAB-001639	Mon Nov 09, 2026 05:00 AM	platelets	289.0 x10^3/uL
LAB-001625	Tue Nov 10, 2026 05:00 AM	creatinine	0.86 mg/dL
LAB-001629	Tue Nov 10, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-001633	Tue Nov 10, 2026 05:00 AM	hemoglobin	13.74 g/dL
LAB-001640	Tue Nov 10, 2026 05:00 AM	wbc	10.14 x10^3/uL
LAB-001641	Tue Nov 10, 2026 05:00 AM	platelets	297.0 x10^3/uL

Vitals (48)

Vitals
Row	When	Kind	Value	Detail
VIT-004711	Sat Nov 07, 2026 09:30 PM	spo2	96.0	room air
VIT-004712	Sat Nov 07, 2026 09:30 PM	rr	19.0
VIT-004727	Sat Nov 07, 2026 09:30 PM	temp_c	37.0
VIT-004728	Sat Nov 07, 2026 09:30 PM	hr	87.0
VIT-004729	Sat Nov 07, 2026 09:30 PM	map	80.0
VIT-004730	Sat Nov 07, 2026 09:30 PM	gcs	15.0
VIT-004713	Sun Nov 08, 2026 05:30 AM	spo2	96.0	room air
VIT-004714	Sun Nov 08, 2026 05:30 AM	rr	17.0
VIT-004731	Sun Nov 08, 2026 05:30 AM	temp_c	36.5
VIT-004732	Sun Nov 08, 2026 05:30 AM	hr	81.0
VIT-004733	Sun Nov 08, 2026 05:30 AM	map	75.0
VIT-004734	Sun Nov 08, 2026 05:30 AM	gcs	15.0
VIT-004715	Sun Nov 08, 2026 01:30 PM	spo2	96.0	room air
VIT-004716	Sun Nov 08, 2026 01:30 PM	rr	15.0
VIT-004735	Sun Nov 08, 2026 01:30 PM	temp_c	37.4
VIT-004736	Sun Nov 08, 2026 01:30 PM	hr	90.0
VIT-004737	Sun Nov 08, 2026 01:30 PM	map	74.0
VIT-004738	Sun Nov 08, 2026 01:30 PM	gcs	15.0
VIT-004717	Sun Nov 08, 2026 09:30 PM	spo2	94.0	room air
VIT-004718	Sun Nov 08, 2026 09:30 PM	rr	15.0
VIT-004739	Sun Nov 08, 2026 09:30 PM	temp_c	37.1
VIT-004740	Sun Nov 08, 2026 09:30 PM	hr	84.0
VIT-004741	Sun Nov 08, 2026 09:30 PM	map	88.0
VIT-004742	Sun Nov 08, 2026 09:30 PM	gcs	15.0
VIT-004719	Mon Nov 09, 2026 05:30 AM	spo2	96.0	room air
VIT-004720	Mon Nov 09, 2026 05:30 AM	rr	17.0
VIT-004743	Mon Nov 09, 2026 05:30 AM	temp_c	37.5
VIT-004744	Mon Nov 09, 2026 05:30 AM	hr	75.0
VIT-004745	Mon Nov 09, 2026 05:30 AM	map	83.0
VIT-004746	Mon Nov 09, 2026 05:30 AM	gcs	15.0
VIT-004721	Mon Nov 09, 2026 01:30 PM	spo2	94.0	room air
VIT-004722	Mon Nov 09, 2026 01:30 PM	rr	20.0
VIT-004747	Mon Nov 09, 2026 01:30 PM	temp_c	36.8
VIT-004748	Mon Nov 09, 2026 01:30 PM	hr	78.0
VIT-004749	Mon Nov 09, 2026 01:30 PM	map	90.0
VIT-004750	Mon Nov 09, 2026 01:30 PM	gcs	15.0
VIT-004723	Mon Nov 09, 2026 09:30 PM	spo2	96.0	room air
VIT-004724	Mon Nov 09, 2026 09:30 PM	rr	17.0
VIT-004751	Mon Nov 09, 2026 09:30 PM	temp_c	37.4
VIT-004752	Mon Nov 09, 2026 09:30 PM	hr	69.0
VIT-004753	Mon Nov 09, 2026 09:30 PM	map	75.0
VIT-004754	Mon Nov 09, 2026 09:30 PM	gcs	15.0
VIT-004725	Tue Nov 10, 2026 05:30 AM	spo2	95.0	room air
VIT-004726	Tue Nov 10, 2026 05:30 AM	rr	14.0
VIT-004755	Tue Nov 10, 2026 05:30 AM	temp_c	36.9
VIT-004756	Tue Nov 10, 2026 05:30 AM	hr	83.0
VIT-004757	Tue Nov 10, 2026 05:30 AM	map	76.0
VIT-004758	Tue Nov 10, 2026 05:30 AM	gcs	15.0

Medications, orders, echo, history (0)

Notes

History and physical · DOC-000163 · Dr. Isaac Abernath (attending) · Sun Nov 08, 2026 12:10 AM

Source document DOC-000163: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Gideon Pemberton   MRN: MRN92060182   Admitted: 2026-11-07 21:10
Service: Pulmonology   Attending: Dr. Isaac Abernath

History of present illness: 52-year-old woman admitted with COPD exacerbation. 
Past medical history: GERD, type 2 diabetes.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. COPD exacerbation: bronchodilators and steroids.

Nutrition assessment · DOC-000162 · Viggo Ravensworth, RD (dietitian) · Mon Nov 09, 2026 01:10 AM

Cited facts from this note (8)

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

Show source for fat_loss

… Context: acute illness Intake: estimated energy intake 70% of needs for 9 days. Weight history: 5.1% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
fluid_accumulation: none · cited p. 1, line 7 · confidence 0.90

Show source for fluid_accumulation

… ke 70% of needs for 9 days. Weight history: 5.1% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
intake_days: 9 · cited p. 1, line 5 · confidence 0.95

Show source for intake_days

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Gideon Pemberton MRN: MRN92060182 Context: acute illness Intake: estimated energy intake 70% of needs for 9 days. Weight history: 5.1% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Rec …
intake_pct: 70 · cited p. 1, line 5 · confidence 0.95

Show source for intake_pct

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Gideon Pemberton MRN: MRN92060182 Context: acute illness Intake: estimated energy intake 70% of needs for 9 days. Weight history: 5.1% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Rec …
muscle_loss: mild · cited p. 1, line 7 · confidence 0.90

Show source for muscle_loss

… estimated energy intake 70% of needs for 9 days. Weight history: 5.1% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. 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: Gideon Pemberton MRN: MRN92060182 Context: acute illness Intake: estimated energy intake 70% of needs for 9 days. Weight history: 5.1% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutane …
weight_loss_days: 30 · cited p. 1, line 6 · confidence 0.95

Show source for weight_loss_days

… stered Dietitian) Patient: Gideon Pemberton MRN: MRN92060182 Context: acute illness Intake: estimated energy intake 70% of needs for 9 days. Weight history: 5.1% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; cal …
weight_loss_pct: 5.1 · cited p. 1, line 6 · confidence 0.95

Show source for weight_loss_pct

… stered Dietitian) Patient: Gideon Pemberton MRN: MRN92060182 Context: acute illness Intake: estimated energy intake 70% of needs for 9 days. Weight history: 5.1% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; cal …

Source document DOC-000162: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Gideon Pemberton   MRN: MRN92060182

Context: acute illness
Intake: estimated energy intake 70% of needs for 9 days.
Weight history: 5.1% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Recommendations: high-protein oral supplement; calorie counts; weekly weights.

Progress note · DOC-000164 · Dr. Isaac Abernath (attending) · Tue Nov 10, 2026 01:10 AM

Source document DOC-000164: Progress note (synthetic)

PROGRESS NOTE (Attending)
Patient: Gideon Pemberton   MRN: MRN92060182   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. COPD exacerbation: continue current management.

Attending: Dr. Isaac Abernath

Discharge summary · DOC-000165 · Dr. Isaac Abernath (attending) · Tue Nov 10, 2026 12:50 PM

Source document DOC-000165: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Gideon Pemberton   MRN: MRN92060182
Admitted 2026-11-07; discharged 2026-11-10.

Discharge diagnoses:
- COPD exacerbation
- GERD
- type 2 diabetes

Disposition: home with follow-up.