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-00062: Hana Abernath

53M · MRN79945113 · Hospital Medicine · admitted Fri Oct 30, 2026 11:17 AM · discharged Tue Nov 03, 2026 01:25 PM · attending Dr. Isaac Abernath · resident Dr. Keira Upfield · 166 cm, 50.0 kg

Documented diagnoses (current)

Principal: “sepsis” · A41.9 Sepsis, unspecified organism
“urinary tract infection” · N39.0 Urinary tract infection, site not specified
“malnourished” · E46 Unspecified protein-calorie malnutrition
“CKD” · N18.9 Chronic kidney disease, unspecified
“acute kidney injury” · N17.9 Acute kidney failure, unspecified
“congestive heart failure” · I50.9 Heart failure, unspecified
“hypoxemia” · R09.02 Hypoxemia
“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 872 Septicemia or severe sepsis without MV >96 hours without MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 871.

Queries and events

No queries yet.

All rules applied

Rule Criteria Finding Outcome

Acute kidney injury

Criteria met

No gap

Supported as documented (N17.9).

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=2.487, t.ratio_s1=1.5, creat_rise_48h=0.83, t.rise_abs=0.3, uo_hours_lt_0_5=18, 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=2.487, t.ratio_s3=3.0, creat_peak=3.78, t.scr_s3=4.0, rrt_started=False, uo_hours_lt_0_3=0, t.uo_s3_h=24, anuria_hours=0, 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=2.487, t.ratio_s2=2.0, uo_hours_lt_0_5=18, t.uo_s2_h=12	true
derived: stage	`case(stage3, 3, stage2, 2, meets_definition, 1, 0)`	stage3=False, stage2=True, meets_definition=True	2
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=0.83, t.rise_abs=0.3, rrt_started=False	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	stage=2, baseline_independent=True	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=14.96, t.hb_m=13, t.hb_f=12	false
derived: acute_fall	`hgb_drop >= t.drop_major or prbc_units >= t.prbc_major`	hgb_drop=0.3, t.drop_major=2.0, prbc_units=0, t.prbc_major=2	false
outcome: met	`bleeding_documented and anaemic and acute_fall`	bleeding_documented=False, anaemic=False, acute_fall=False	false
outcome: anaemia_only	`anaemic and hgb_drop < t.drop_min and prbc_units == 0`	anaemic=False, hgb_drop=0.3, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=14.96, anaemic=False	true

Chronic kidney disease

Criteria met

Specificity gap

Documented “CKD” (N18.9); criteria support the more specific Chronic kidney disease stage 3a (N18.31).

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=294, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=52.8, egfr_late=54.5	54.5
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=52.8, t.g2=60, egfr_late=54.5	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=54.5, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15	G3a
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=52.8, egfr_late=54.5, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=54.5, t.g2=60	false
outcome: g3a	`category == 'G3a'`	category=G3a	true

Heart failure

Criteria met

Specificity gap

Documented “congestive heart failure” (I50.9); criteria support the more specific Acute on chronic systolic (HFrEF) heart failure (I50.23).

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=1775.0, 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=True	3
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=34.0, t.ref=40, t.pres=50	systolic
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=34.0, 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=3, hf_history=True	acute on chronic
outcome: improved_ef	`improved`	improved=False	false
outcome: midrange	`hf_type == 'midrange'`	hf_type=systolic	false
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	hf_type=systolic, 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=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 not met

Clinical validation gap

Documented “malnourished” (E46) but the criteria are not met: 4 characteristics assessed and none met.

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 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=53, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=18.1, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=18.1, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=18.1, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=18.1, 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

Specificity gap

Documented “hypoxemia” (R09.02); criteria support the more specific Acute respiratory failure with hypoxia (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=86.0, pao2_min_ra=54.0, pf_min=257	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=86.0, t.spo2_ra=88, pao2_min_ra=54.0, t.pao2=60, pf_min=257, t.pf=300	true
derived: distress	`coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support`	rr_max=32.0, 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

Supported as documented (A41.9).

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=39.2, t.t_hi=38, temp_min_48h=38.6, t.t_lo=36	true
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=122.0, t.hr=90	true
derived: sirs_rr	`coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false)`	rr_max_48h=32.0, 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=18.58, t.wbc_hi=12, wbc_min_48h=16.31, t.wbc_lo=4, bands_max_48h=unknown, t.bands=10	true
derived: sirs_count	`count(sirs_temp, sirs_hr, sirs_rr, sirs_wbc)`	sirs_temp=True, sirs_hr=True, sirs_rr=True, sirs_wbc=True	4
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=257, 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=83.0	2
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=0.95	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=64.0	1
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=3.78	3
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=1.52	1
derived: sofa_delta	`sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline`	sofa_resp=2, sofa_coag=2, sofa_liver=0, sofa_cardio=1, sofa_cns=0, sofa_renal=3, sofa_renal_baseline=1	7
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=7, t.sofa_delta=2	true
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=True, sirs_count=4, t.sirs_min=2	true
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=2.36, 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=True	true

Structured data

Labs (32)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-002094	Wed Nov 19, 2025 09:15 AM	creatinine	1.56 mg/dL
LAB-002095	Thu Sep 10, 2026 10:05 AM	creatinine	1.52 mg/dL
LAB-002102	Fri Oct 30, 2026 11:42 AM	pao2	54.0 mmHg
LAB-002103	Fri Oct 30, 2026 11:42 AM	fio2	21.0 %
LAB-002096	Fri Oct 30, 2026 12:17 PM	creatinine	2.95 mg/dL
LAB-002101	Fri Oct 30, 2026 12:17 PM	bnp	1775.0 pg/mL
LAB-002104	Fri Oct 30, 2026 12:17 PM	sodium	137.0 mmol/L
LAB-002109	Fri Oct 30, 2026 12:17 PM	hemoglobin	15.22 g/dL
LAB-002114	Fri Oct 30, 2026 12:17 PM	wbc	18.28 x10^3/uL
LAB-002115	Fri Oct 30, 2026 12:17 PM	platelets	83.0 x10^3/uL
LAB-002124	Fri Oct 30, 2026 12:17 PM	bilirubin	0.95 mg/dL
LAB-002125	Fri Oct 30, 2026 12:17 PM	lactate	2.36 mmol/L
LAB-002097	Sat Oct 31, 2026 05:00 AM	creatinine	3.78 mg/dL
LAB-002105	Sat Oct 31, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-002110	Sat Oct 31, 2026 05:00 AM	hemoglobin	14.96 g/dL
LAB-002116	Sat Oct 31, 2026 05:00 AM	wbc	16.31 x10^3/uL
LAB-002117	Sat Oct 31, 2026 05:00 AM	platelets	85.0 x10^3/uL
LAB-002098	Sun Nov 01, 2026 05:00 AM	creatinine	3.4 mg/dL
LAB-002106	Sun Nov 01, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-002111	Sun Nov 01, 2026 05:00 AM	hemoglobin	15.34 g/dL
LAB-002118	Sun Nov 01, 2026 05:00 AM	wbc	18.58 x10^3/uL
LAB-002119	Sun Nov 01, 2026 05:00 AM	platelets	88.0 x10^3/uL
LAB-002099	Mon Nov 02, 2026 05:00 AM	creatinine	2.84 mg/dL
LAB-002107	Mon Nov 02, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-002112	Mon Nov 02, 2026 05:00 AM	hemoglobin	14.97 g/dL
LAB-002120	Mon Nov 02, 2026 05:00 AM	wbc	7.82 x10^3/uL
LAB-002121	Mon Nov 02, 2026 05:00 AM	platelets	190.0 x10^3/uL
LAB-002100	Tue Nov 03, 2026 05:00 AM	creatinine	2.34 mg/dL
LAB-002108	Tue Nov 03, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-002113	Tue Nov 03, 2026 05:00 AM	hemoglobin	15.41 g/dL
LAB-002122	Tue Nov 03, 2026 05:00 AM	wbc	10.3 x10^3/uL
LAB-002123	Tue Nov 03, 2026 05:00 AM	platelets	233.0 x10^3/uL

Vitals (99)

Vitals
Row	When	Kind	Value	Detail
VIT-006025	Fri Oct 30, 2026 11:37 AM	spo2	86.0	room air
VIT-006026	Fri Oct 30, 2026 11:37 AM	rr	32.0
VIT-006064	Fri Oct 30, 2026 11:37 AM	temp_c	39.0
VIT-006065	Fri Oct 30, 2026 11:37 AM	hr	116.0
VIT-006066	Fri Oct 30, 2026 11:37 AM	map	67.0
VIT-006067	Fri Oct 30, 2026 11:37 AM	gcs	15.0
VIT-006027	Fri Oct 30, 2026 11:47 AM	o2_lpm	6.0	nasal cannula
VIT-006017	Fri Oct 30, 2026 05:17 PM	urine_ml_6h	330.0
VIT-006028	Fri Oct 30, 2026 07:37 PM	spo2	92.0	nasal cannula
VIT-006029	Fri Oct 30, 2026 07:37 PM	rr	23.0
VIT-006030	Fri Oct 30, 2026 07:37 PM	o2_lpm	3.0	nasal cannula
VIT-006068	Fri Oct 30, 2026 07:37 PM	temp_c	38.9
VIT-006069	Fri Oct 30, 2026 07:37 PM	hr	117.0
VIT-006070	Fri Oct 30, 2026 07:37 PM	map	65.0
VIT-006071	Fri Oct 30, 2026 07:37 PM	gcs	15.0
VIT-006018	Fri Oct 30, 2026 11:17 PM	urine_ml_6h	126.0
VIT-006031	Sat Oct 31, 2026 03:37 AM	spo2	92.0	nasal cannula
VIT-006032	Sat Oct 31, 2026 03:37 AM	rr	25.0
VIT-006033	Sat Oct 31, 2026 03:37 AM	o2_lpm	3.0	nasal cannula
VIT-006072	Sat Oct 31, 2026 03:37 AM	temp_c	38.9
VIT-006073	Sat Oct 31, 2026 03:37 AM	hr	122.0
VIT-006074	Sat Oct 31, 2026 03:37 AM	map	66.0
VIT-006075	Sat Oct 31, 2026 03:37 AM	gcs	15.0
VIT-006019	Sat Oct 31, 2026 05:17 AM	urine_ml_6h	126.0
VIT-006020	Sat Oct 31, 2026 11:17 AM	urine_ml_6h	126.0
VIT-006034	Sat Oct 31, 2026 11:37 AM	spo2	94.0	nasal cannula
VIT-006035	Sat Oct 31, 2026 11:37 AM	rr	21.0
VIT-006036	Sat Oct 31, 2026 11:37 AM	o2_lpm	4.0	nasal cannula
VIT-006076	Sat Oct 31, 2026 11:37 AM	temp_c	39.0
VIT-006077	Sat Oct 31, 2026 11:37 AM	hr	117.0
VIT-006078	Sat Oct 31, 2026 11:37 AM	map	64.0
VIT-006079	Sat Oct 31, 2026 11:37 AM	gcs	15.0
VIT-006021	Sat Oct 31, 2026 05:17 PM	urine_ml_6h	330.0
VIT-006037	Sat Oct 31, 2026 07:37 PM	spo2	91.0	nasal cannula
VIT-006038	Sat Oct 31, 2026 07:37 PM	rr	22.0
VIT-006039	Sat Oct 31, 2026 07:37 PM	o2_lpm	2.0	nasal cannula
VIT-006080	Sat Oct 31, 2026 07:37 PM	temp_c	38.6
VIT-006081	Sat Oct 31, 2026 07:37 PM	hr	121.0
VIT-006082	Sat Oct 31, 2026 07:37 PM	map	66.0
VIT-006083	Sat Oct 31, 2026 07:37 PM	gcs	15.0
VIT-006022	Sat Oct 31, 2026 11:17 PM	urine_ml_6h	330.0
VIT-006040	Sun Nov 01, 2026 03:37 AM	spo2	95.0	nasal cannula
VIT-006041	Sun Nov 01, 2026 03:37 AM	rr	25.0
VIT-006042	Sun Nov 01, 2026 03:37 AM	o2_lpm	2.0	nasal cannula
VIT-006084	Sun Nov 01, 2026 03:37 AM	temp_c	39.2
VIT-006085	Sun Nov 01, 2026 03:37 AM	hr	114.0
VIT-006086	Sun Nov 01, 2026 03:37 AM	map	64.0
VIT-006087	Sun Nov 01, 2026 03:37 AM	gcs	15.0
VIT-006023	Sun Nov 01, 2026 05:17 AM	urine_ml_6h	330.0
VIT-006024	Sun Nov 01, 2026 11:17 AM	urine_ml_6h	330.0
VIT-006043	Sun Nov 01, 2026 11:37 AM	spo2	95.0	nasal cannula
VIT-006044	Sun Nov 01, 2026 11:37 AM	rr	24.0
VIT-006045	Sun Nov 01, 2026 11:37 AM	o2_lpm	2.0	nasal cannula
VIT-006088	Sun Nov 01, 2026 11:37 AM	temp_c	37.3
VIT-006089	Sun Nov 01, 2026 11:37 AM	hr	88.0
VIT-006090	Sun Nov 01, 2026 11:37 AM	map	81.0
VIT-006091	Sun Nov 01, 2026 11:37 AM	gcs	15.0
VIT-006046	Sun Nov 01, 2026 07:37 PM	spo2	95.0	nasal cannula
VIT-006047	Sun Nov 01, 2026 07:37 PM	rr	26.0
VIT-006048	Sun Nov 01, 2026 07:37 PM	o2_lpm	3.0	nasal cannula
VIT-006092	Sun Nov 01, 2026 07:37 PM	temp_c	37.0
VIT-006093	Sun Nov 01, 2026 07:37 PM	hr	74.0
VIT-006094	Sun Nov 01, 2026 07:37 PM	map	79.0
VIT-006095	Sun Nov 01, 2026 07:37 PM	gcs	15.0
VIT-006049	Mon Nov 02, 2026 03:37 AM	spo2	92.0	nasal cannula
VIT-006050	Mon Nov 02, 2026 03:37 AM	rr	21.0
VIT-006051	Mon Nov 02, 2026 03:37 AM	o2_lpm	4.0	nasal cannula
VIT-006096	Mon Nov 02, 2026 03:37 AM	temp_c	36.6
VIT-006097	Mon Nov 02, 2026 03:37 AM	hr	91.0
VIT-006098	Mon Nov 02, 2026 03:37 AM	map	75.0
VIT-006099	Mon Nov 02, 2026 03:37 AM	gcs	15.0
VIT-006052	Mon Nov 02, 2026 11:37 AM	spo2	95.0	nasal cannula
VIT-006053	Mon Nov 02, 2026 11:37 AM	rr	26.0
VIT-006054	Mon Nov 02, 2026 11:37 AM	o2_lpm	2.0	nasal cannula
VIT-006100	Mon Nov 02, 2026 11:37 AM	temp_c	37.5
VIT-006101	Mon Nov 02, 2026 11:37 AM	hr	79.0
VIT-006102	Mon Nov 02, 2026 11:37 AM	map	84.0
VIT-006103	Mon Nov 02, 2026 11:37 AM	gcs	15.0
VIT-006055	Mon Nov 02, 2026 07:37 PM	spo2	91.0	nasal cannula
VIT-006056	Mon Nov 02, 2026 07:37 PM	rr	22.0
VIT-006057	Mon Nov 02, 2026 07:37 PM	o2_lpm	4.0	nasal cannula
VIT-006104	Mon Nov 02, 2026 07:37 PM	temp_c	37.1
VIT-006105	Mon Nov 02, 2026 07:37 PM	hr	83.0
VIT-006106	Mon Nov 02, 2026 07:37 PM	map	78.0
VIT-006107	Mon Nov 02, 2026 07:37 PM	gcs	15.0
VIT-006058	Tue Nov 03, 2026 03:37 AM	spo2	91.0	nasal cannula
VIT-006059	Tue Nov 03, 2026 03:37 AM	rr	25.0
VIT-006060	Tue Nov 03, 2026 03:37 AM	o2_lpm	2.0	nasal cannula
VIT-006108	Tue Nov 03, 2026 03:37 AM	temp_c	36.7
VIT-006109	Tue Nov 03, 2026 03:37 AM	hr	72.0
VIT-006110	Tue Nov 03, 2026 03:37 AM	map	75.0
VIT-006111	Tue Nov 03, 2026 03:37 AM	gcs	15.0
VIT-006061	Tue Nov 03, 2026 11:37 AM	spo2	95.0	nasal cannula
VIT-006062	Tue Nov 03, 2026 11:37 AM	rr	25.0
VIT-006063	Tue Nov 03, 2026 11:37 AM	o2_lpm	4.0	nasal cannula
VIT-006112	Tue Nov 03, 2026 11:37 AM	temp_c	37.6
VIT-006113	Tue Nov 03, 2026 11:37 AM	hr	92.0
VIT-006114	Tue Nov 03, 2026 11:37 AM	map	90.0
VIT-006115	Tue Nov 03, 2026 11:37 AM	gcs	15.0

Medications, orders, echo, history (12)

MED-000230 10-30 12:17 ceftriaxone per protocol IV
MED-000231 10-31 05:00 piperacillin-tazobactam per protocol IV
MED-000232 11-01 05:00 piperacillin-tazobactam per protocol IV
MED-000233 10-30 08:00 furosemide 40 mg IV
MED-000234 10-30 20:00 furosemide 40 mg IV
MED-000235 10-31 08:00 furosemide 40 mg IV
MED-000236 10-31 20:00 furosemide 40 mg IV
MED-000237 11-01 08:00 furosemide 40 mg IV
MED-000238 11-01 20:00 furosemide 40 mg IV
ORD-000050 10-30 11:47 blood_culture: blood cultures x2
ECH-000029 2026-10-31 echo LVEF 34.0%
HX-000022 history: heart failure with reduced ejection fraction

Notes

History and physical · DOC-000214 · Dr. Keira Upfield (resident) · Fri Oct 30, 2026 02:17 PM

Cited facts from this note (2)

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

Show source for infection_source

… rvice: Hospital Medicine Attending: Dr. Isaac Abernath History of present illness: 53-year-old man admitted with sepsis. Urinalysis with pyuria; treated for urinary tract infection with cefepime. Past medical history: heart failure with reduced ejection fraction, hypertension, hyperlipidemia, type 2 diabetes. Review of systems otherwise n …
work_of_breathing: increased · cited p. 1, line 8 · confidence 0.90

Show source for work_of_breathing

… edical history: heart failure with reduced ejection fraction, hypertension, hyperlipidemia, type 2 diabetes. Review of systems otherwise negative. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. Sepsis: antibiotics, fluids. 2. Urinary tract infection: antibiotics. 3. CKD: renally dose medications.

Source document DOC-000214: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Hana Abernath   MRN: MRN79945113   Admitted: 2026-10-30 11:17
Service: Hospital Medicine   Attending: Dr. Isaac Abernath

History of present illness: 53-year-old man admitted with sepsis. Urinalysis with pyuria; treated for urinary tract infection with cefepime.
Past medical history: heart failure with reduced ejection fraction, hypertension, hyperlipidemia, type 2 diabetes.
Review of systems otherwise negative.
Exam: Lungs: increased work of breathing with accessory muscle use.
Assessment and plan:
1. Sepsis: antibiotics, fluids.
2. Urinary tract infection: antibiotics.
3. CKD: renally dose medications.

Nutrition assessment · DOC-000213 · Viggo Ravensworth, RD (dietitian) · Sat Oct 31, 2026 02:17 PM

Cited facts from this note (5)

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

Show source for fat_loss

… MRN: MRN79945113 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: Hana Abernath MRN: MRN79945113 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: Hana Abernath MRN: MRN79945113 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-000213: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Hana Abernath   MRN: MRN79945113

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-000215 · Dr. Keira Upfield (resident) · Sun Nov 01, 2026 12:17 PM

Source document DOC-000215: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Hana Abernath   MRN: MRN79945113   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.
2. Malnourished: dietitian following.
3. Acute kidney injury: trend creatinine, hold nephrotoxins, strict intake and output.
4. Congestive heart failure: diuresis and daily weights; monitor electrolytes.
5. Hypoxemia: supplemental oxygen, wean as tolerated.

Resident: Dr. Keira Upfield   Attending cosign: completed

Discharge summary · DOC-000216 · Dr. Isaac Abernath (attending) · Tue Nov 03, 2026 01:25 PM

Source document DOC-000216: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Hana Abernath   MRN: MRN79945113
Admitted 2026-10-30; discharged 2026-11-03.

Discharge diagnoses:
- sepsis
- urinary tract infection
- malnourished
- CKD
- acute kidney injury
- congestive heart failure
- hypoxemia
- hypertension
- hyperlipidemia
- type 2 diabetes

Disposition: home with follow-up.