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-00073: Pilar Lindqvist

87F · MRN59811775 · Hospital Medicine · admitted Mon Nov 09, 2026 04:43 PM · discharged Thu Nov 12, 2026 04:38 PM · attending Dr. Rosalind Quillan · resident Dr. Keira Upfield · 170 cm, 52.2 kg

Documented diagnoses (current)

Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“malnutrition” · E46 Unspecified protein-calorie malnutrition
“AKI” · N17.9 Acute kidney failure, unspecified
“acute blood loss anemia” · D62 Acute posthemorrhagic anemia
“GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis
“hypertension” · I10 Essential (primary) hypertension

Illustrative grouping now: MS-DRG 194 Simple pneumonia and pleurisy with CC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 194.

Queries and events

No queries yet.

All rules applied

Rule Criteria Finding Outcome

Acute kidney injury

Criteria not met

Clinical validation gap

Documented “AKI” (N17.9) but the criteria are not met: KDIGO creatinine and urine-output criteria not met.

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=1.043, t.ratio_s1=1.5, creat_rise_48h=0.08, 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=1.043, t.ratio_s3=3.0, creat_peak=1.46, 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=1.043, 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=0.08, 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 met

No gap

Supported as documented (D62).

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=8.24, 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=3.7, t.drop_major=2.0, prbc_units=2, t.prbc_major=2	true
outcome: met	`bleeding_documented and anaemic and acute_fall`	bleeding_documented=True, anaemic=True, acute_fall=True	true

Chronic kidney disease

Criteria met

Specificity gap

Criteria support Chronic kidney disease stage 3b (N18.32); no corresponding diagnosis is documented.

Trace

Rule trace (rule ckd v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: chronic	`egfr_n >= 2 and egfr_span_days >= t.chronic_days`	egfr_n=2, egfr_span_days=214, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=42.1, egfr_late=36.4	42.1
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=42.1, t.g2=60, egfr_late=36.4	true
derived: category	`case(staging_egfr >= t.g2, 'G1-G2', staging_egfr >= t.g3a, 'G3a', staging_egfr >= t.g3b, 'G3b', staging_egfr >= t.g4, 'G4', 'G5')`	staging_egfr=42.1, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15	G3b
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=42.1, egfr_late=36.4, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=42.1, t.g2=60	false
outcome: g3a	`category == 'G3a'`	category=G3b	false
outcome: g3b	`category == 'G3b'`	category=G3b	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=140.0, 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=140.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=140.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=140.0, t.low=135	true

Malnutrition

Criteria met

Specificity gap

Documented “malnutrition” (E46); criteria support the more specific Moderate (non-severe) protein-calorie malnutrition (acute illness context) (E44.0).

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=60.0, t.a_sev_intake_pct=50, intake_days=10.0, 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=60.0, t.a_mod_intake_pct=75, intake_days=10.0, 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=5.4	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=5.4	true
derived: c_sev_intake	`intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=60.0, t.c_intake_pct=75, intake_days=10.0, 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=60.0, t.c_intake_pct=75, intake_days=10.0, 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=5.4	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=5.4	true
derived: n_assessed	`known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced)`	intake_pct=60.0, wt_loss_pct=5.4, 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=87, 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 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=37.3, t.t_hi=38, temp_min_48h=36.6, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=87.0, 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=7.95, t.wbc_hi=12, wbc_min_48h=7.0, 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=179.0	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=0.62	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=76.0	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=1.44	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=1.4	1
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=1	0
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=0, t.sofa_delta=2	false
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=True, sirs_count=0, t.sirs_min=2	false
derived: shock	`sepsis3 and norepi_max_48h > 0 and coalesce(lactate_max_48h > t.lactate, false)`	sepsis3=False, norepi_max_48h=0.0, lactate_max_48h=unknown, t.lactate=2	false
outcome: no_infection	`not infection_documented`	infection_documented=True	false
outcome: septic_shock	`shock`	shock=False	false
outcome: both	`sepsis3 and sepsis2`	sepsis3=False, sepsis2=False	false
outcome: sepsis3_only	`sepsis3`	sepsis3=False	false
outcome: definitions_disagree	`sepsis2`	sepsis2=False	false
outcome: neither	`true`	—	true

Structured data

Labs (23)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-002492	Tue Dec 16, 2025 09:15 AM	creatinine	1.24 mg/dL
LAB-002493	Sun Jul 19, 2026 10:05 AM	creatinine	1.4 mg/dL
LAB-002494	Mon Nov 09, 2026 05:43 PM	creatinine	1.41 mg/dL
LAB-002498	Mon Nov 09, 2026 05:43 PM	sodium	141.0 mmol/L
LAB-002502	Mon Nov 09, 2026 05:43 PM	hemoglobin	11.96 g/dL
LAB-002506	Mon Nov 09, 2026 05:43 PM	wbc	7.95 x10^3/uL
LAB-002507	Mon Nov 09, 2026 05:43 PM	platelets	196.0 x10^3/uL
LAB-002514	Mon Nov 09, 2026 05:43 PM	bilirubin	0.62 mg/dL
LAB-002495	Tue Nov 10, 2026 05:00 AM	creatinine	1.44 mg/dL
LAB-002499	Tue Nov 10, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-002503	Tue Nov 10, 2026 05:00 AM	hemoglobin	9.73 g/dL
LAB-002508	Tue Nov 10, 2026 05:00 AM	wbc	7.32 x10^3/uL
LAB-002509	Tue Nov 10, 2026 05:00 AM	platelets	179.0 x10^3/uL
LAB-002496	Wed Nov 11, 2026 05:00 AM	creatinine	1.38 mg/dL
LAB-002500	Wed Nov 11, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-002504	Wed Nov 11, 2026 05:00 AM	hemoglobin	8.24 g/dL
LAB-002510	Wed Nov 11, 2026 05:00 AM	wbc	7.0 x10^3/uL
LAB-002511	Wed Nov 11, 2026 05:00 AM	platelets	272.0 x10^3/uL
LAB-002497	Thu Nov 12, 2026 05:00 AM	creatinine	1.46 mg/dL
LAB-002501	Thu Nov 12, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-002505	Thu Nov 12, 2026 05:00 AM	hemoglobin	9.04 g/dL
LAB-002512	Thu Nov 12, 2026 05:00 AM	wbc	6.79 x10^3/uL
LAB-002513	Thu Nov 12, 2026 05:00 AM	platelets	174.0 x10^3/uL

Vitals (54)

Vitals
Row	When	Kind	Value	Detail
VIT-007204	Mon Nov 09, 2026 05:03 PM	spo2	96.0	room air
VIT-007205	Mon Nov 09, 2026 05:03 PM	rr	20.0
VIT-007222	Mon Nov 09, 2026 05:03 PM	temp_c	36.6
VIT-007223	Mon Nov 09, 2026 05:03 PM	hr	77.0
VIT-007224	Mon Nov 09, 2026 05:03 PM	map	85.0
VIT-007225	Mon Nov 09, 2026 05:03 PM	gcs	15.0
VIT-007206	Tue Nov 10, 2026 01:03 AM	spo2	99.0	room air
VIT-007207	Tue Nov 10, 2026 01:03 AM	rr	16.0
VIT-007226	Tue Nov 10, 2026 01:03 AM	temp_c	37.3
VIT-007227	Tue Nov 10, 2026 01:03 AM	hr	77.0
VIT-007228	Tue Nov 10, 2026 01:03 AM	map	80.0
VIT-007229	Tue Nov 10, 2026 01:03 AM	gcs	15.0
VIT-007208	Tue Nov 10, 2026 09:03 AM	spo2	95.0	room air
VIT-007209	Tue Nov 10, 2026 09:03 AM	rr	15.0
VIT-007230	Tue Nov 10, 2026 09:03 AM	temp_c	36.7
VIT-007231	Tue Nov 10, 2026 09:03 AM	hr	72.0
VIT-007232	Tue Nov 10, 2026 09:03 AM	map	78.0
VIT-007233	Tue Nov 10, 2026 09:03 AM	gcs	15.0
VIT-007210	Tue Nov 10, 2026 05:03 PM	spo2	95.0	room air
VIT-007211	Tue Nov 10, 2026 05:03 PM	rr	17.0
VIT-007234	Tue Nov 10, 2026 05:03 PM	temp_c	36.8
VIT-007235	Tue Nov 10, 2026 05:03 PM	hr	76.0
VIT-007236	Tue Nov 10, 2026 05:03 PM	map	83.0
VIT-007237	Tue Nov 10, 2026 05:03 PM	gcs	15.0
VIT-007212	Wed Nov 11, 2026 01:03 AM	spo2	95.0	room air
VIT-007213	Wed Nov 11, 2026 01:03 AM	rr	19.0
VIT-007238	Wed Nov 11, 2026 01:03 AM	temp_c	37.2
VIT-007239	Wed Nov 11, 2026 01:03 AM	hr	69.0
VIT-007240	Wed Nov 11, 2026 01:03 AM	map	76.0
VIT-007241	Wed Nov 11, 2026 01:03 AM	gcs	15.0
VIT-007214	Wed Nov 11, 2026 09:03 AM	spo2	96.0	room air
VIT-007215	Wed Nov 11, 2026 09:03 AM	rr	17.0
VIT-007242	Wed Nov 11, 2026 09:03 AM	temp_c	37.2
VIT-007243	Wed Nov 11, 2026 09:03 AM	hr	87.0
VIT-007244	Wed Nov 11, 2026 09:03 AM	map	83.0
VIT-007245	Wed Nov 11, 2026 09:03 AM	gcs	15.0
VIT-007216	Wed Nov 11, 2026 05:03 PM	spo2	99.0	room air
VIT-007217	Wed Nov 11, 2026 05:03 PM	rr	14.0
VIT-007246	Wed Nov 11, 2026 05:03 PM	temp_c	36.8
VIT-007247	Wed Nov 11, 2026 05:03 PM	hr	80.0
VIT-007248	Wed Nov 11, 2026 05:03 PM	map	88.0
VIT-007249	Wed Nov 11, 2026 05:03 PM	gcs	15.0
VIT-007218	Thu Nov 12, 2026 01:03 AM	spo2	95.0	room air
VIT-007219	Thu Nov 12, 2026 01:03 AM	rr	14.0
VIT-007250	Thu Nov 12, 2026 01:03 AM	temp_c	37.0
VIT-007251	Thu Nov 12, 2026 01:03 AM	hr	77.0
VIT-007252	Thu Nov 12, 2026 01:03 AM	map	88.0
VIT-007253	Thu Nov 12, 2026 01:03 AM	gcs	15.0
VIT-007220	Thu Nov 12, 2026 09:03 AM	spo2	99.0	room air
VIT-007221	Thu Nov 12, 2026 09:03 AM	rr	15.0
VIT-007254	Thu Nov 12, 2026 09:03 AM	temp_c	36.6
VIT-007255	Thu Nov 12, 2026 09:03 AM	hr	84.0
VIT-007256	Thu Nov 12, 2026 09:03 AM	map	81.0
VIT-007257	Thu Nov 12, 2026 09:03 AM	gcs	15.0

Medications, orders, echo, history (5)

MED-000285 11-09 17:43 cefepime per protocol IV
MED-000286 11-10 05:00 cefepime per protocol IV
MED-000287 11-11 05:00 piperacillin-tazobactam per protocol IV
ORD-000064 11-09 17:13 blood_culture: blood cultures x2
ORD-000065 11-10 09:00 transfusion_prbc: transfuse PRBC

Notes

History and physical · DOC-000252 · Dr. Keira Upfield (resident) · Mon Nov 09, 2026 07:43 PM

Cited facts from this note (2)

bleeding_source: black tarry stools · cited p. 1, line 5 · confidence 0.85

Show source for bleeding_source

… ed with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Hospital course complicated by black tarry stools. Past medical history: GERD, hypertension. Review of systems otherwise negative. Exam: Lungs: clear to auscultation bilaterally. Assessment and plan: 1. Commun …
infection_source: left lower lobe pneumonia · cited p. 1, line 5 · confidence 0.85

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… ospital Medicine Attending: Dr. Rosalind Quillan History of present illness: 87-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Hospital course complicated by black tarry stools. Past medical history: GERD, hypertension. Review of systems o …

Source document DOC-000252: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Pilar Lindqvist   MRN: MRN59811775   Admitted: 2026-11-09 16:43
Service: Hospital Medicine   Attending: Dr. Rosalind Quillan

History of present illness: 87-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Hospital course complicated by black tarry stools.
Past medical history: GERD, hypertension.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Nutrition assessment · DOC-000251 · Viggo Ravensworth, RD (dietitian) · Tue Nov 10, 2026 09:43 PM

Cited facts from this note (8)

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

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… ontext: acute illness Intake: estimated energy intake 60% of needs for 10 days. Weight history: 5.4% 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

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… e 60% of needs for 10 days. Weight history: 5.4% 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: 10 · cited p. 1, line 5 · confidence 0.95

Show source for intake_days

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Pilar Lindqvist MRN: MRN59811775 Context: acute illness Intake: estimated energy intake 60% of needs for 10 days. Weight history: 5.4% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Rec …
intake_pct: 60 · cited p. 1, line 5 · confidence 0.95

Show source for intake_pct

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Pilar Lindqvist MRN: MRN59811775 Context: acute illness Intake: estimated energy intake 60% of needs for 10 days. Weight history: 5.4% 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

… stimated energy intake 60% of needs for 10 days. Weight history: 5.4% 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: Pilar Lindqvist MRN: MRN59811775 Context: acute illness Intake: estimated energy intake 60% of needs for 10 days. Weight history: 5.4% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutan …
weight_loss_days: 30 · cited p. 1, line 6 · confidence 0.95

Show source for weight_loss_days

… stered Dietitian) Patient: Pilar Lindqvist MRN: MRN59811775 Context: acute illness Intake: estimated energy intake 60% of needs for 10 days. Weight history: 5.4% 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: 5.4 · cited p. 1, line 6 · confidence 0.95

Show source for weight_loss_pct

… stered Dietitian) Patient: Pilar Lindqvist MRN: MRN59811775 Context: acute illness Intake: estimated energy intake 60% of needs for 10 days. Weight history: 5.4% 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-000251: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Pilar Lindqvist   MRN: MRN59811775

Context: acute illness
Intake: estimated energy intake 60% of needs for 10 days.
Weight history: 5.4% 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-000253 · Dr. Keira Upfield (resident) · Wed Nov 11, 2026 05:43 PM

Source document DOC-000253: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Pilar Lindqvist   MRN: MRN59811775   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.
2. Malnutrition: dietitian following.
3. AKI: trend creatinine, hold nephrotoxins, strict intake and output.
4. Acute blood loss anemia: trend hemoglobin, transfuse if needed.

Resident: Dr. Keira Upfield   Attending cosign: completed

Discharge summary · DOC-000254 · Dr. Rosalind Quillan (attending) · Thu Nov 12, 2026 04:38 PM

Source document DOC-000254: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Pilar Lindqvist   MRN: MRN59811775
Admitted 2026-11-09; discharged 2026-11-12.

Discharge diagnoses:
- community-acquired pneumonia
- malnutrition
- AKI
- acute blood loss anemia
- GERD
- hypertension

Disposition: home with follow-up.