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-00082: Kenji Lindqvist

79F · MRN39526312 · Hospital Medicine · admitted Wed Oct 28, 2026 08:46 AM · discharged Mon Nov 02, 2026 04:02 PM · attending Dr. Gideon Zeller · resident Dr. Keira Upfield · 157 cm, 50.6 kg

Documented diagnoses (current)

Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“AKI” · N17.9 Acute kidney failure, unspecified
“anemia” · D64.9 Anemia, unspecified
“type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications
“hyperlipidemia” · E78.5 Hyperlipidemia, unspecified

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 195.

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=0.07, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, t.uo_s1_h=6	false
derived: stage3	`meets_definition and (creat_ratio >= t.ratio_s3 or creat_peak >= t.scr_s3 or rrt_started or coalesce(uo_hours_lt_0_3 >= t.uo_s3_h, false) or coalesce(anuria_hours >= t.anuria_h, false))`	meets_definition=False, creat_ratio=1.043, t.ratio_s3=3.0, creat_peak=1.69, 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=0.07, t.rise_abs=0.3, rrt_started=False	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	stage=0, baseline_independent=True	false
outcome: aki_presumed_baseline	`stage >= 1`	stage=0	false
outcome: not_met	`stage == 0`	stage=0	true

Acute blood loss anaemia

Criteria met

No gap

Supported as documented (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=F, hgb_nadir=10.03, 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=0.0, 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=True, acute_fall=False	false
outcome: anaemia_only	`anaemic and hgb_drop < t.drop_min and prbc_units == 0`	anaemic=True, hgb_drop=0.0, t.drop_min=1.0, prbc_units=0	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=253, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=39.3, egfr_late=32.1	39.3
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=39.3, t.g2=60, egfr_late=32.1	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=39.3, 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=39.3, egfr_late=32.1, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=39.3, 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=138.0, 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=138.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=138.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=138.0, t.low=135	true

Malnutrition

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

Trace

Rule trace (rule malnutrition v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: a_sev_intake	`intake_pct <= t.a_sev_intake_pct and intake_days >= t.a_sev_intake_days`	intake_pct=unknown, t.a_sev_intake_pct=50, intake_days=unknown, t.a_sev_intake_days=5	unknown
derived: a_mod_intake	`intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days`	intake_pct=unknown, t.a_mod_intake_pct=75, intake_days=unknown, t.a_mod_intake_days=7	unknown
derived: a_sev_wt	`(wt_loss_days <= 7 and wt_loss_pct > 2) or (wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: a_mod_wt	`(wt_loss_days <= 7 and wt_loss_pct >= 1) or (wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: c_sev_intake	`intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=unknown, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30	unknown
derived: c_mod_intake	`intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=unknown, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30	unknown
derived: c_sev_wt	`(wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5) or (wt_loss_days <= 183 and wt_loss_pct > 10) or (wt_loss_days <= 366 and wt_loss_pct > 20)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: c_mod_wt	`(wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5) or (wt_loss_days <= 183 and wt_loss_pct >= 10) or (wt_loss_days <= 366 and wt_loss_pct >= 20)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: n_assessed	`known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced)`	intake_pct=unknown, wt_loss_pct=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown	0
derived: n_severe	`case(nutr_context == 'acute', count(a_sev_intake, a_sev_wt, fat_loss >= 2, muscle_loss >= 2, fluid >= 2, grip_reduced), nutr_context == 'chronic', count(c_sev_intake, c_sev_wt, fat_loss >= 3, muscle_loss >= 3, fluid >= 3, grip_reduced), null)`	nutr_context=unknown, a_sev_intake=unknown, a_sev_wt=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown, c_sev_intake=unknown, c_sev_wt=unknown	unknown
derived: n_moderate	`case(nutr_context == 'acute', count(a_sev_intake or a_mod_intake, a_sev_wt or a_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), nutr_context == 'chronic', count(c_sev_intake or c_mod_intake, c_sev_wt or c_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), null)`	nutr_context=unknown, a_sev_intake=unknown, a_mod_intake=unknown, a_sev_wt=unknown, a_mod_wt=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown, c_sev_intake=unknown, c_mod_intake=unknown, c_sev_wt=unknown, c_mod_wt=unknown	unknown
outcome: severe	`n_severe >= 2`	n_severe=unknown	unknown
outcome: moderate	`n_moderate >= 2`	n_moderate=unknown	unknown
outcome: one_characteristic	`n_moderate == 1`	n_moderate=unknown	unknown
outcome: not_met	`n_moderate == 0 and n_assessed >= 2`	n_moderate=unknown, n_assessed=0	false

Obesity

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule obesity v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
outcome: not_adult	`age < t.adult`	age=79, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=20.5, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=20.5, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=20.5, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=20.5, 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=37.0, 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=9.09, t.wbc_hi=12, wbc_min_48h=5.7, 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=182.0	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=0.71	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=1.69	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=1.62	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 (33)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-002782	Wed Jan 07, 2026 09:15 AM	creatinine	1.37 mg/dL
LAB-002783	Fri Sep 18, 2026 10:05 AM	creatinine	1.62 mg/dL
LAB-002784	Wed Oct 28, 2026 09:46 AM	creatinine	1.69 mg/dL
LAB-002790	Wed Oct 28, 2026 09:46 AM	sodium	138.0 mmol/L
LAB-002796	Wed Oct 28, 2026 09:46 AM	hemoglobin	10.03 g/dL
LAB-002802	Wed Oct 28, 2026 09:46 AM	wbc	6.83 x10^3/uL
LAB-002803	Wed Oct 28, 2026 09:46 AM	platelets	294.0 x10^3/uL
LAB-002814	Wed Oct 28, 2026 09:46 AM	bilirubin	0.71 mg/dL
LAB-002785	Thu Oct 29, 2026 05:00 AM	creatinine	1.62 mg/dL
LAB-002791	Thu Oct 29, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-002797	Thu Oct 29, 2026 05:00 AM	hemoglobin	10.04 g/dL
LAB-002804	Thu Oct 29, 2026 05:00 AM	wbc	5.7 x10^3/uL
LAB-002805	Thu Oct 29, 2026 05:00 AM	platelets	284.0 x10^3/uL
LAB-002786	Fri Oct 30, 2026 05:00 AM	creatinine	1.6 mg/dL
LAB-002792	Fri Oct 30, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-002798	Fri Oct 30, 2026 05:00 AM	hemoglobin	10.04 g/dL
LAB-002806	Fri Oct 30, 2026 05:00 AM	wbc	9.09 x10^3/uL
LAB-002807	Fri Oct 30, 2026 05:00 AM	platelets	182.0 x10^3/uL
LAB-002787	Sat Oct 31, 2026 05:00 AM	creatinine	1.61 mg/dL
LAB-002793	Sat Oct 31, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-002799	Sat Oct 31, 2026 05:00 AM	hemoglobin	10.04 g/dL
LAB-002808	Sat Oct 31, 2026 05:00 AM	wbc	10.82 x10^3/uL
LAB-002809	Sat Oct 31, 2026 05:00 AM	platelets	205.0 x10^3/uL
LAB-002788	Sun Nov 01, 2026 05:00 AM	creatinine	1.68 mg/dL
LAB-002794	Sun Nov 01, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-002800	Sun Nov 01, 2026 05:00 AM	hemoglobin	10.19 g/dL
LAB-002810	Sun Nov 01, 2026 05:00 AM	wbc	10.7 x10^3/uL
LAB-002811	Sun Nov 01, 2026 05:00 AM	platelets	294.0 x10^3/uL
LAB-002789	Mon Nov 02, 2026 05:00 AM	creatinine	1.68 mg/dL
LAB-002795	Mon Nov 02, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-002801	Mon Nov 02, 2026 05:00 AM	hemoglobin	10.27 g/dL
LAB-002812	Mon Nov 02, 2026 05:00 AM	wbc	7.74 x10^3/uL
LAB-002813	Mon Nov 02, 2026 05:00 AM	platelets	173.0 x10^3/uL

Vitals (96)

Vitals
Row	When	Kind	Value	Detail
VIT-008057	Wed Oct 28, 2026 09:06 AM	spo2	95.0	room air
VIT-008058	Wed Oct 28, 2026 09:06 AM	rr	20.0
VIT-008089	Wed Oct 28, 2026 09:06 AM	temp_c	37.0
VIT-008090	Wed Oct 28, 2026 09:06 AM	hr	76.0
VIT-008091	Wed Oct 28, 2026 09:06 AM	map	85.0
VIT-008092	Wed Oct 28, 2026 09:06 AM	gcs	15.0
VIT-008059	Wed Oct 28, 2026 05:06 PM	spo2	96.0	room air
VIT-008060	Wed Oct 28, 2026 05:06 PM	rr	18.0
VIT-008093	Wed Oct 28, 2026 05:06 PM	temp_c	37.5
VIT-008094	Wed Oct 28, 2026 05:06 PM	hr	85.0
VIT-008095	Wed Oct 28, 2026 05:06 PM	map	81.0
VIT-008096	Wed Oct 28, 2026 05:06 PM	gcs	15.0
VIT-008061	Thu Oct 29, 2026 01:06 AM	spo2	98.0	room air
VIT-008062	Thu Oct 29, 2026 01:06 AM	rr	16.0
VIT-008097	Thu Oct 29, 2026 01:06 AM	temp_c	37.3
VIT-008098	Thu Oct 29, 2026 01:06 AM	hr	70.0
VIT-008099	Thu Oct 29, 2026 01:06 AM	map	85.0
VIT-008100	Thu Oct 29, 2026 01:06 AM	gcs	15.0
VIT-008063	Thu Oct 29, 2026 09:06 AM	spo2	97.0	room air
VIT-008064	Thu Oct 29, 2026 09:06 AM	rr	20.0
VIT-008101	Thu Oct 29, 2026 09:06 AM	temp_c	37.5
VIT-008102	Thu Oct 29, 2026 09:06 AM	hr	78.0
VIT-008103	Thu Oct 29, 2026 09:06 AM	map	74.0
VIT-008104	Thu Oct 29, 2026 09:06 AM	gcs	15.0
VIT-008065	Thu Oct 29, 2026 05:06 PM	spo2	98.0	room air
VIT-008066	Thu Oct 29, 2026 05:06 PM	rr	17.0
VIT-008105	Thu Oct 29, 2026 05:06 PM	temp_c	37.1
VIT-008106	Thu Oct 29, 2026 05:06 PM	hr	69.0
VIT-008107	Thu Oct 29, 2026 05:06 PM	map	92.0
VIT-008108	Thu Oct 29, 2026 05:06 PM	gcs	15.0
VIT-008067	Fri Oct 30, 2026 01:06 AM	spo2	97.0	room air
VIT-008068	Fri Oct 30, 2026 01:06 AM	rr	14.0
VIT-008109	Fri Oct 30, 2026 01:06 AM	temp_c	37.3
VIT-008110	Fri Oct 30, 2026 01:06 AM	hr	87.0
VIT-008111	Fri Oct 30, 2026 01:06 AM	map	78.0
VIT-008112	Fri Oct 30, 2026 01:06 AM	gcs	15.0
VIT-008069	Fri Oct 30, 2026 09:06 AM	spo2	98.0	room air
VIT-008070	Fri Oct 30, 2026 09:06 AM	rr	17.0
VIT-008113	Fri Oct 30, 2026 09:06 AM	temp_c	37.3
VIT-008114	Fri Oct 30, 2026 09:06 AM	hr	91.0
VIT-008115	Fri Oct 30, 2026 09:06 AM	map	78.0
VIT-008116	Fri Oct 30, 2026 09:06 AM	gcs	15.0
VIT-008071	Fri Oct 30, 2026 05:06 PM	spo2	97.0	room air
VIT-008072	Fri Oct 30, 2026 05:06 PM	rr	14.0
VIT-008117	Fri Oct 30, 2026 05:06 PM	temp_c	37.4
VIT-008118	Fri Oct 30, 2026 05:06 PM	hr	78.0
VIT-008119	Fri Oct 30, 2026 05:06 PM	map	85.0
VIT-008120	Fri Oct 30, 2026 05:06 PM	gcs	15.0
VIT-008073	Sat Oct 31, 2026 01:06 AM	spo2	96.0	room air
VIT-008074	Sat Oct 31, 2026 01:06 AM	rr	20.0
VIT-008121	Sat Oct 31, 2026 01:06 AM	temp_c	36.8
VIT-008122	Sat Oct 31, 2026 01:06 AM	hr	81.0
VIT-008123	Sat Oct 31, 2026 01:06 AM	map	85.0
VIT-008124	Sat Oct 31, 2026 01:06 AM	gcs	15.0
VIT-008075	Sat Oct 31, 2026 09:06 AM	spo2	99.0	room air
VIT-008076	Sat Oct 31, 2026 09:06 AM	rr	16.0
VIT-008125	Sat Oct 31, 2026 09:06 AM	temp_c	37.0
VIT-008126	Sat Oct 31, 2026 09:06 AM	hr	85.0
VIT-008127	Sat Oct 31, 2026 09:06 AM	map	75.0
VIT-008128	Sat Oct 31, 2026 09:06 AM	gcs	15.0
VIT-008077	Sat Oct 31, 2026 05:06 PM	spo2	97.0	room air
VIT-008078	Sat Oct 31, 2026 05:06 PM	rr	18.0
VIT-008129	Sat Oct 31, 2026 05:06 PM	temp_c	37.2
VIT-008130	Sat Oct 31, 2026 05:06 PM	hr	91.0
VIT-008131	Sat Oct 31, 2026 05:06 PM	map	81.0
VIT-008132	Sat Oct 31, 2026 05:06 PM	gcs	15.0
VIT-008079	Sun Nov 01, 2026 01:06 AM	spo2	94.0	room air
VIT-008080	Sun Nov 01, 2026 01:06 AM	rr	17.0
VIT-008133	Sun Nov 01, 2026 01:06 AM	temp_c	36.9
VIT-008134	Sun Nov 01, 2026 01:06 AM	hr	91.0
VIT-008135	Sun Nov 01, 2026 01:06 AM	map	84.0
VIT-008136	Sun Nov 01, 2026 01:06 AM	gcs	15.0
VIT-008081	Sun Nov 01, 2026 09:06 AM	spo2	95.0	room air
VIT-008082	Sun Nov 01, 2026 09:06 AM	rr	17.0
VIT-008137	Sun Nov 01, 2026 09:06 AM	temp_c	37.2
VIT-008138	Sun Nov 01, 2026 09:06 AM	hr	72.0
VIT-008139	Sun Nov 01, 2026 09:06 AM	map	82.0
VIT-008140	Sun Nov 01, 2026 09:06 AM	gcs	15.0
VIT-008083	Sun Nov 01, 2026 05:06 PM	spo2	98.0	room air
VIT-008084	Sun Nov 01, 2026 05:06 PM	rr	20.0
VIT-008141	Sun Nov 01, 2026 05:06 PM	temp_c	36.5
VIT-008142	Sun Nov 01, 2026 05:06 PM	hr	86.0
VIT-008143	Sun Nov 01, 2026 05:06 PM	map	84.0
VIT-008144	Sun Nov 01, 2026 05:06 PM	gcs	15.0
VIT-008085	Mon Nov 02, 2026 01:06 AM	spo2	97.0	room air
VIT-008086	Mon Nov 02, 2026 01:06 AM	rr	14.0
VIT-008145	Mon Nov 02, 2026 01:06 AM	temp_c	36.8
VIT-008146	Mon Nov 02, 2026 01:06 AM	hr	87.0
VIT-008147	Mon Nov 02, 2026 01:06 AM	map	91.0
VIT-008148	Mon Nov 02, 2026 01:06 AM	gcs	15.0
VIT-008087	Mon Nov 02, 2026 09:06 AM	spo2	95.0	room air
VIT-008088	Mon Nov 02, 2026 09:06 AM	rr	14.0
VIT-008149	Mon Nov 02, 2026 09:06 AM	temp_c	36.5
VIT-008150	Mon Nov 02, 2026 09:06 AM	hr	85.0
VIT-008151	Mon Nov 02, 2026 09:06 AM	map	79.0
VIT-008152	Mon Nov 02, 2026 09:06 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000315 10-28 09:46 piperacillin-tazobactam per protocol IV
MED-000316 10-29 05:00 ceftriaxone per protocol IV
MED-000317 10-30 05:00 piperacillin-tazobactam per protocol IV
ORD-000072 10-28 09:16 blood_culture: blood cultures x2

Notes

History and physical · DOC-000279 · Dr. Keira Upfield (resident) · Wed Oct 28, 2026 11:46 AM

Cited facts from this note (1)

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

Show source for infection_source

… : Hospital Medicine Attending: Dr. Gideon Zeller History of present illness: 79-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: type 2 diabetes, hyperlipidemia. Review of systems otherwise negative. Exam: Lungs: scatte …

Source document DOC-000279: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Kenji Lindqvist   MRN: MRN39526312   Admitted: 2026-10-28 08:46
Service: Hospital Medicine   Attending: Dr. Gideon Zeller

History of present illness: 79-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: type 2 diabetes, hyperlipidemia.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Progress note · DOC-000280 · Dr. Keira Upfield (resident) · Fri Oct 30, 2026 08:46 AM

Source document DOC-000280: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Kenji Lindqvist   MRN: MRN39526312   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. AKI: trend creatinine, hold nephrotoxins, strict intake and output.
3. Anemia: trend hemoglobin.

Resident: Dr. Keira Upfield   Attending cosign: completed

Discharge summary · DOC-000281 · Dr. Gideon Zeller (attending) · Mon Nov 02, 2026 04:02 PM

Source document DOC-000281: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Kenji Lindqvist   MRN: MRN39526312
Admitted 2026-10-28; discharged 2026-11-02.

Discharge diagnoses:
- community-acquired pneumonia
- AKI
- anemia
- type 2 diabetes
- hyperlipidemia

Disposition: home with follow-up.