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-00103: Kenji Oyelaran

78M · MRN88784734 · Hospital Medicine · admitted Mon Nov 09, 2026 09:04 AM · in hospital · attending Dr. Gideon Zeller · resident Dr. Camila Oyelaran · 162 cm, 113.9 kg

Documented diagnoses (current)

Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“obesity” · E66.9 Obesity, unspecified
“acute blood loss anemia” · D62 Acute posthemorrhagic anemia

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

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=1.037, t.ratio_s1=1.5, creat_rise_48h=0.04, 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=1.037, t.ratio_s3=3.0, creat_peak=0.85, 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=1.037, 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=0.04, 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

Clinical judgement required

Clinical judgement required: Haemoglobin fell 1.4 g/dL without transfusion (between 1 and 2 g/dL).

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=10.34, 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=1.4, t.drop_major=2.0, prbc_units=0, t.prbc_major=2	false
outcome: met	`bleeding_documented and anaemic and acute_fall`	bleeding_documented=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=1.4, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=10.34, anaemic=True	false
outcome: no_source	`anaemic and acute_fall`	anaemic=True, acute_fall=False	false
outcome: borderline	`anaemic`	anaemic=True	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=252, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=90.2, egfr_late=89.9	90.2
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=90.2, t.g2=60, egfr_late=89.9	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=90.2, 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=90.2, egfr_late=89.9, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=90.2, 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 not met

No gap

Not documented and not supported.

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 met

Specificity gap

Documented “obesity” (E66.9); criteria support the more specific Obesity, class 3 (E66.813).

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=78, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=43.4, t.c3=40	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=37.6, 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=10.8, t.wbc_hi=12, wbc_min_48h=5.87, 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=185.0	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=1.0	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=0.85	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=0.82	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=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 (28)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-003500	Mon Dec 15, 2025 09:15 AM	creatinine	0.81 mg/dL
LAB-003501	Tue Aug 25, 2026 10:05 AM	creatinine	0.82 mg/dL
LAB-003502	Mon Nov 09, 2026 10:04 AM	creatinine	0.81 mg/dL
LAB-003507	Mon Nov 09, 2026 10:04 AM	sodium	137.0 mmol/L
LAB-003512	Mon Nov 09, 2026 10:04 AM	hemoglobin	11.74 g/dL
LAB-003517	Mon Nov 09, 2026 10:04 AM	wbc	10.8 x10^3/uL
LAB-003518	Mon Nov 09, 2026 10:04 AM	platelets	262.0 x10^3/uL
LAB-003527	Mon Nov 09, 2026 10:04 AM	bilirubin	1.0 mg/dL
LAB-003503	Tue Nov 10, 2026 05:00 AM	creatinine	0.84 mg/dL
LAB-003508	Tue Nov 10, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-003513	Tue Nov 10, 2026 05:00 AM	hemoglobin	10.94 g/dL
LAB-003519	Tue Nov 10, 2026 05:00 AM	wbc	8.41 x10^3/uL
LAB-003520	Tue Nov 10, 2026 05:00 AM	platelets	220.0 x10^3/uL
LAB-003504	Wed Nov 11, 2026 05:00 AM	creatinine	0.85 mg/dL
LAB-003509	Wed Nov 11, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-003514	Wed Nov 11, 2026 05:00 AM	hemoglobin	10.34 g/dL
LAB-003521	Wed Nov 11, 2026 05:00 AM	wbc	5.87 x10^3/uL
LAB-003522	Wed Nov 11, 2026 05:00 AM	platelets	185.0 x10^3/uL
LAB-003505	Thu Nov 12, 2026 05:00 AM	creatinine	0.82 mg/dL
LAB-003510	Thu Nov 12, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-003515	Thu Nov 12, 2026 05:00 AM	hemoglobin	10.44 g/dL
LAB-003523	Thu Nov 12, 2026 05:00 AM	wbc	8.05 x10^3/uL
LAB-003524	Thu Nov 12, 2026 05:00 AM	platelets	278.0 x10^3/uL
LAB-003506	Fri Nov 13, 2026 05:00 AM	creatinine	0.85 mg/dL
LAB-003511	Fri Nov 13, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-003516	Fri Nov 13, 2026 05:00 AM	hemoglobin	10.54 g/dL
LAB-003525	Fri Nov 13, 2026 05:00 AM	wbc	5.94 x10^3/uL
LAB-003526	Fri Nov 13, 2026 05:00 AM	platelets	277.0 x10^3/uL

Vitals (78)

Vitals
Row	When	Kind	Value	Detail
VIT-010059	Mon Nov 09, 2026 09:24 AM	spo2	95.0	room air
VIT-010060	Mon Nov 09, 2026 09:24 AM	rr	20.0
VIT-010085	Mon Nov 09, 2026 09:24 AM	temp_c	37.2
VIT-010086	Mon Nov 09, 2026 09:24 AM	hr	82.0
VIT-010087	Mon Nov 09, 2026 09:24 AM	map	80.0
VIT-010088	Mon Nov 09, 2026 09:24 AM	gcs	15.0
VIT-010061	Mon Nov 09, 2026 05:24 PM	spo2	96.0	room air
VIT-010062	Mon Nov 09, 2026 05:24 PM	rr	20.0
VIT-010089	Mon Nov 09, 2026 05:24 PM	temp_c	36.6
VIT-010090	Mon Nov 09, 2026 05:24 PM	hr	84.0
VIT-010091	Mon Nov 09, 2026 05:24 PM	map	92.0
VIT-010092	Mon Nov 09, 2026 05:24 PM	gcs	15.0
VIT-010063	Tue Nov 10, 2026 01:24 AM	spo2	98.0	room air
VIT-010064	Tue Nov 10, 2026 01:24 AM	rr	18.0
VIT-010093	Tue Nov 10, 2026 01:24 AM	temp_c	37.2
VIT-010094	Tue Nov 10, 2026 01:24 AM	hr	90.0
VIT-010095	Tue Nov 10, 2026 01:24 AM	map	84.0
VIT-010096	Tue Nov 10, 2026 01:24 AM	gcs	15.0
VIT-010065	Tue Nov 10, 2026 09:24 AM	spo2	97.0	room air
VIT-010066	Tue Nov 10, 2026 09:24 AM	rr	20.0
VIT-010097	Tue Nov 10, 2026 09:24 AM	temp_c	37.6
VIT-010098	Tue Nov 10, 2026 09:24 AM	hr	76.0
VIT-010099	Tue Nov 10, 2026 09:24 AM	map	92.0
VIT-010100	Tue Nov 10, 2026 09:24 AM	gcs	15.0
VIT-010067	Tue Nov 10, 2026 05:24 PM	spo2	99.0	room air
VIT-010068	Tue Nov 10, 2026 05:24 PM	rr	19.0
VIT-010101	Tue Nov 10, 2026 05:24 PM	temp_c	36.5
VIT-010102	Tue Nov 10, 2026 05:24 PM	hr	83.0
VIT-010103	Tue Nov 10, 2026 05:24 PM	map	87.0
VIT-010104	Tue Nov 10, 2026 05:24 PM	gcs	15.0
VIT-010069	Wed Nov 11, 2026 01:24 AM	spo2	97.0	room air
VIT-010070	Wed Nov 11, 2026 01:24 AM	rr	18.0
VIT-010105	Wed Nov 11, 2026 01:24 AM	temp_c	37.6
VIT-010106	Wed Nov 11, 2026 01:24 AM	hr	85.0
VIT-010107	Wed Nov 11, 2026 01:24 AM	map	74.0
VIT-010108	Wed Nov 11, 2026 01:24 AM	gcs	15.0
VIT-010071	Wed Nov 11, 2026 09:24 AM	spo2	96.0	room air
VIT-010072	Wed Nov 11, 2026 09:24 AM	rr	19.0
VIT-010109	Wed Nov 11, 2026 09:24 AM	temp_c	36.7
VIT-010110	Wed Nov 11, 2026 09:24 AM	hr	77.0
VIT-010111	Wed Nov 11, 2026 09:24 AM	map	79.0
VIT-010112	Wed Nov 11, 2026 09:24 AM	gcs	15.0
VIT-010073	Wed Nov 11, 2026 05:24 PM	spo2	99.0	room air
VIT-010074	Wed Nov 11, 2026 05:24 PM	rr	19.0
VIT-010113	Wed Nov 11, 2026 05:24 PM	temp_c	37.5
VIT-010114	Wed Nov 11, 2026 05:24 PM	hr	76.0
VIT-010115	Wed Nov 11, 2026 05:24 PM	map	79.0
VIT-010116	Wed Nov 11, 2026 05:24 PM	gcs	15.0
VIT-010075	Thu Nov 12, 2026 01:24 AM	spo2	99.0	room air
VIT-010076	Thu Nov 12, 2026 01:24 AM	rr	15.0
VIT-010117	Thu Nov 12, 2026 01:24 AM	temp_c	36.6
VIT-010118	Thu Nov 12, 2026 01:24 AM	hr	84.0
VIT-010119	Thu Nov 12, 2026 01:24 AM	map	92.0
VIT-010120	Thu Nov 12, 2026 01:24 AM	gcs	15.0
VIT-010077	Thu Nov 12, 2026 09:24 AM	spo2	99.0	room air
VIT-010078	Thu Nov 12, 2026 09:24 AM	rr	20.0
VIT-010121	Thu Nov 12, 2026 09:24 AM	temp_c	37.3
VIT-010122	Thu Nov 12, 2026 09:24 AM	hr	79.0
VIT-010123	Thu Nov 12, 2026 09:24 AM	map	87.0
VIT-010124	Thu Nov 12, 2026 09:24 AM	gcs	15.0
VIT-010079	Thu Nov 12, 2026 05:24 PM	spo2	98.0	room air
VIT-010080	Thu Nov 12, 2026 05:24 PM	rr	18.0
VIT-010125	Thu Nov 12, 2026 05:24 PM	temp_c	36.8
VIT-010126	Thu Nov 12, 2026 05:24 PM	hr	71.0
VIT-010127	Thu Nov 12, 2026 05:24 PM	map	84.0
VIT-010128	Thu Nov 12, 2026 05:24 PM	gcs	15.0
VIT-010081	Fri Nov 13, 2026 01:24 AM	spo2	99.0	room air
VIT-010082	Fri Nov 13, 2026 01:24 AM	rr	16.0
VIT-010129	Fri Nov 13, 2026 01:24 AM	temp_c	37.5
VIT-010130	Fri Nov 13, 2026 01:24 AM	hr	90.0
VIT-010131	Fri Nov 13, 2026 01:24 AM	map	76.0
VIT-010132	Fri Nov 13, 2026 01:24 AM	gcs	15.0
VIT-010083	Fri Nov 13, 2026 09:24 AM	spo2	96.0	room air
VIT-010084	Fri Nov 13, 2026 09:24 AM	rr	20.0
VIT-010133	Fri Nov 13, 2026 09:24 AM	temp_c	36.5
VIT-010134	Fri Nov 13, 2026 09:24 AM	hr	80.0
VIT-010135	Fri Nov 13, 2026 09:24 AM	map	85.0
VIT-010136	Fri Nov 13, 2026 09:24 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000400 11-09 10:04 piperacillin-tazobactam per protocol IV
MED-000401 11-10 05:00 ceftriaxone per protocol IV
MED-000402 11-11 05:00 ceftriaxone per protocol IV
ORD-000090 11-09 09:34 blood_culture: blood cultures x2

Notes

History and physical · DOC-000347 · Dr. Camila Oyelaran (resident) · Mon Nov 09, 2026 12:04 PM

Cited facts from this note (1)

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

Show source for infection_source

… ce: Hospital Medicine Attending: Dr. Gideon Zeller History of present illness: 78-year-old man admitted with community-acquired pneumonia. Chest x-ray shows right lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: none significant. Review of systems otherwise negative. Exam: Lungs: scattered crackles at …

Source document DOC-000347: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Kenji Oyelaran   MRN: MRN88784734   Admitted: 2026-11-09 09:04
Service: Hospital Medicine   Attending: Dr. Gideon Zeller

History of present illness: 78-year-old man admitted with community-acquired pneumonia. Chest x-ray shows right lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: none significant.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Nutrition assessment · DOC-000346 · Vera Pemberton, RD (dietitian) · Tue Nov 10, 2026 01:04 PM

Cited facts from this note (5)

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

Show source for fat_loss

… MRN: MRN88784734 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: Kenji Oyelaran MRN: MRN88784734 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: Kenji Oyelaran MRN: MRN88784734 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-000346: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Kenji Oyelaran   MRN: MRN88784734

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-000348 · Dr. Camila Oyelaran (resident) · Fri Nov 13, 2026 10:55 AM · awaiting cosign

Source document DOC-000348: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Kenji Oyelaran   MRN: MRN88784734   Hospital day 5

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Community-acquired pneumonia: continue current management.
2. Obesity: counsel on weight.
3. Acute blood loss anemia: trend hemoglobin, transfuse if needed.

Resident: Dr. Camila Oyelaran   Attending cosign: pending