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-00122: Bodhi Foxhall

47M · MRN54136198 · Hospital Medicine · admitted Thu Nov 05, 2026 09:13 PM · discharged Mon Nov 09, 2026 10:39 AM · attending Dr. Kenji Stavros · 174 cm, 53.6 kg

Documented diagnoses (current)

Principal: “urinary tract infection” · N39.0 Urinary tract infection, site not specified
“severe malnutrition” · E43 Unspecified severe protein-calorie malnutrition
“AKI” · N17.9 Acute kidney failure, unspecified
“heart failure” · I50.9 Heart failure, unspecified
“acute respiratory failure with hypoxia” · J96.01 Acute respiratory failure with hypoxia
“anemia” · D64.9 Anemia, unspecified
“type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications
“hypertension” · I10 Essential (primary) hypertension
“GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis

Illustrative grouping now: MS-DRG 689 Kidney and urinary tract infections with MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 689.

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=1.056, 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=1.056, t.ratio_s3=3.0, creat_peak=1.14, 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=1.056, 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

Specificity gap

Documented “anemia” (D64.9); criteria support the more specific Acute blood loss anemia (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=M, hgb_nadir=10.61, 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=2.7, 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

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=329, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=87.1, egfr_late=85.2	87.1
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=87.1, t.g2=60, egfr_late=85.2	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=87.1, 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=87.1, egfr_late=85.2, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=87.1, t.g2=60	true

Heart failure

Criteria met

Specificity gap

Documented “heart failure” (I50.9); criteria support the more specific Acute systolic (HFrEF) heart failure (I50.21).

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=698.0, 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=21.0, 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=21.0, 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=False	acute
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	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	hf_type=systolic, acuity=acute	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=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

Criteria met

Clinical validation gap

Documented “severe malnutrition” (E43) conflicts with what the criteria support (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=11.0, 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=11.0, 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=3.0	false
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=3.0	false
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=11.0, 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=11.0, 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=3.0	false
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=3.0	false
derived: n_assessed	`known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced)`	intake_pct=60.0, wt_loss_pct=3.0, 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=False, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_sev_wt=False	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=True, a_sev_wt=False, a_mod_wt=False, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_mod_intake=False, c_sev_wt=False, c_mod_wt=False	3
outcome: severe	`n_severe >= 2`	n_severe=0	false
outcome: moderate	`n_moderate >= 2`	n_moderate=3	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=47, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=17.7, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=17.7, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=17.7, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=17.7, 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

No gap

Supported as documented (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=85.0, pao2_min_ra=55.0, pf_min=262	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=85.0, t.spo2_ra=88, pao2_min_ra=55.0, t.pao2=60, pf_min=262, t.pf=300	true
derived: distress	`coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support`	rr_max=29.0, 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

Criteria support Sepsis (Sepsis-3); not documented (this rule does not prompt for an undocumented diagnosis).

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=37.4, 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=84.0, 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=29.0, 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=9.22, t.wbc_hi=12, wbc_min_48h=6.61, 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=True, sirs_wbc=False	1
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=262, 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=198.0	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=0.5	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=1.14	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=1.08	0
derived: sofa_delta	`sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline`	sofa_resp=2, sofa_coag=0, sofa_liver=0, sofa_cardio=0, sofa_cns=0, sofa_renal=0, sofa_renal_baseline=0	2
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=2, t.sofa_delta=2	true
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=True, sirs_count=1, t.sirs_min=2	false
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=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=True, sepsis2=False	false
outcome: sepsis3_only	`sepsis3`	sepsis3=True	true

Structured data

Labs (31)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-004137	Mon Sep 29, 2025 09:15 AM	creatinine	1.06 mg/dL
LAB-004138	Mon Aug 24, 2026 10:05 AM	creatinine	1.08 mg/dL
LAB-004145	Thu Nov 05, 2026 09:38 PM	pao2	55.0 mmHg
LAB-004146	Thu Nov 05, 2026 09:38 PM	fio2	21.0 %
LAB-004139	Thu Nov 05, 2026 10:13 PM	creatinine	1.14 mg/dL
LAB-004144	Thu Nov 05, 2026 10:13 PM	bnp	698.0 pg/mL
LAB-004147	Thu Nov 05, 2026 10:13 PM	sodium	141.0 mmol/L
LAB-004152	Thu Nov 05, 2026 10:13 PM	hemoglobin	13.35 g/dL
LAB-004157	Thu Nov 05, 2026 10:13 PM	wbc	8.23 x10^3/uL
LAB-004158	Thu Nov 05, 2026 10:13 PM	platelets	235.0 x10^3/uL
LAB-004167	Thu Nov 05, 2026 10:13 PM	bilirubin	0.5 mg/dL
LAB-004140	Fri Nov 06, 2026 05:00 AM	creatinine	1.12 mg/dL
LAB-004148	Fri Nov 06, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-004153	Fri Nov 06, 2026 05:00 AM	hemoglobin	11.71 g/dL
LAB-004159	Fri Nov 06, 2026 05:00 AM	wbc	6.61 x10^3/uL
LAB-004160	Fri Nov 06, 2026 05:00 AM	platelets	303.0 x10^3/uL
LAB-004141	Sat Nov 07, 2026 05:00 AM	creatinine	1.06 mg/dL
LAB-004149	Sat Nov 07, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-004154	Sat Nov 07, 2026 05:00 AM	hemoglobin	10.61 g/dL
LAB-004161	Sat Nov 07, 2026 05:00 AM	wbc	9.22 x10^3/uL
LAB-004162	Sat Nov 07, 2026 05:00 AM	platelets	198.0 x10^3/uL
LAB-004142	Sun Nov 08, 2026 05:00 AM	creatinine	1.12 mg/dL
LAB-004150	Sun Nov 08, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-004155	Sun Nov 08, 2026 05:00 AM	hemoglobin	11.41 g/dL
LAB-004163	Sun Nov 08, 2026 05:00 AM	wbc	7.46 x10^3/uL
LAB-004164	Sun Nov 08, 2026 05:00 AM	platelets	226.0 x10^3/uL
LAB-004143	Mon Nov 09, 2026 05:00 AM	creatinine	1.13 mg/dL
LAB-004151	Mon Nov 09, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-004156	Mon Nov 09, 2026 05:00 AM	hemoglobin	11.71 g/dL
LAB-004165	Mon Nov 09, 2026 05:00 AM	wbc	9.66 x10^3/uL
LAB-004166	Mon Nov 09, 2026 05:00 AM	platelets	173.0 x10^3/uL

Vitals (77)

Vitals
Row	When	Kind	Value	Detail
VIT-011844	Thu Nov 05, 2026 09:33 PM	spo2	85.0	room air
VIT-011845	Thu Nov 05, 2026 09:33 PM	rr	29.0
VIT-011877	Thu Nov 05, 2026 09:33 PM	temp_c	36.6
VIT-011878	Thu Nov 05, 2026 09:33 PM	hr	73.0
VIT-011879	Thu Nov 05, 2026 09:33 PM	map	80.0
VIT-011880	Thu Nov 05, 2026 09:33 PM	gcs	15.0
VIT-011846	Thu Nov 05, 2026 09:43 PM	o2_lpm	6.0	nasal cannula
VIT-011847	Fri Nov 06, 2026 05:33 AM	spo2	93.0	nasal cannula
VIT-011848	Fri Nov 06, 2026 05:33 AM	rr	26.0
VIT-011849	Fri Nov 06, 2026 05:33 AM	o2_lpm	4.0	nasal cannula
VIT-011881	Fri Nov 06, 2026 05:33 AM	temp_c	36.7
VIT-011882	Fri Nov 06, 2026 05:33 AM	hr	73.0
VIT-011883	Fri Nov 06, 2026 05:33 AM	map	81.0
VIT-011884	Fri Nov 06, 2026 05:33 AM	gcs	15.0
VIT-011850	Fri Nov 06, 2026 01:33 PM	spo2	95.0	nasal cannula
VIT-011851	Fri Nov 06, 2026 01:33 PM	rr	23.0
VIT-011852	Fri Nov 06, 2026 01:33 PM	o2_lpm	4.0	nasal cannula
VIT-011885	Fri Nov 06, 2026 01:33 PM	temp_c	36.9
VIT-011886	Fri Nov 06, 2026 01:33 PM	hr	74.0
VIT-011887	Fri Nov 06, 2026 01:33 PM	map	74.0
VIT-011888	Fri Nov 06, 2026 01:33 PM	gcs	15.0
VIT-011853	Fri Nov 06, 2026 09:33 PM	spo2	92.0	nasal cannula
VIT-011854	Fri Nov 06, 2026 09:33 PM	rr	22.0
VIT-011855	Fri Nov 06, 2026 09:33 PM	o2_lpm	3.0	nasal cannula
VIT-011889	Fri Nov 06, 2026 09:33 PM	temp_c	37.0
VIT-011890	Fri Nov 06, 2026 09:33 PM	hr	77.0
VIT-011891	Fri Nov 06, 2026 09:33 PM	map	76.0
VIT-011892	Fri Nov 06, 2026 09:33 PM	gcs	15.0
VIT-011856	Sat Nov 07, 2026 05:33 AM	spo2	92.0	nasal cannula
VIT-011857	Sat Nov 07, 2026 05:33 AM	rr	21.0
VIT-011858	Sat Nov 07, 2026 05:33 AM	o2_lpm	2.0	nasal cannula
VIT-011893	Sat Nov 07, 2026 05:33 AM	temp_c	37.4
VIT-011894	Sat Nov 07, 2026 05:33 AM	hr	84.0
VIT-011895	Sat Nov 07, 2026 05:33 AM	map	76.0
VIT-011896	Sat Nov 07, 2026 05:33 AM	gcs	15.0
VIT-011859	Sat Nov 07, 2026 01:33 PM	spo2	95.0	nasal cannula
VIT-011860	Sat Nov 07, 2026 01:33 PM	rr	24.0
VIT-011861	Sat Nov 07, 2026 01:33 PM	o2_lpm	4.0	nasal cannula
VIT-011897	Sat Nov 07, 2026 01:33 PM	temp_c	37.1
VIT-011898	Sat Nov 07, 2026 01:33 PM	hr	72.0
VIT-011899	Sat Nov 07, 2026 01:33 PM	map	78.0
VIT-011900	Sat Nov 07, 2026 01:33 PM	gcs	15.0
VIT-011862	Sat Nov 07, 2026 09:33 PM	spo2	94.0	nasal cannula
VIT-011863	Sat Nov 07, 2026 09:33 PM	rr	21.0
VIT-011864	Sat Nov 07, 2026 09:33 PM	o2_lpm	4.0	nasal cannula
VIT-011901	Sat Nov 07, 2026 09:33 PM	temp_c	37.0
VIT-011902	Sat Nov 07, 2026 09:33 PM	hr	81.0
VIT-011903	Sat Nov 07, 2026 09:33 PM	map	87.0
VIT-011904	Sat Nov 07, 2026 09:33 PM	gcs	15.0
VIT-011865	Sun Nov 08, 2026 05:33 AM	spo2	94.0	nasal cannula
VIT-011866	Sun Nov 08, 2026 05:33 AM	rr	25.0
VIT-011867	Sun Nov 08, 2026 05:33 AM	o2_lpm	2.0	nasal cannula
VIT-011905	Sun Nov 08, 2026 05:33 AM	temp_c	37.0
VIT-011906	Sun Nov 08, 2026 05:33 AM	hr	92.0
VIT-011907	Sun Nov 08, 2026 05:33 AM	map	90.0
VIT-011908	Sun Nov 08, 2026 05:33 AM	gcs	15.0
VIT-011868	Sun Nov 08, 2026 01:33 PM	spo2	93.0	nasal cannula
VIT-011869	Sun Nov 08, 2026 01:33 PM	rr	24.0
VIT-011870	Sun Nov 08, 2026 01:33 PM	o2_lpm	3.0	nasal cannula
VIT-011909	Sun Nov 08, 2026 01:33 PM	temp_c	37.5
VIT-011910	Sun Nov 08, 2026 01:33 PM	hr	78.0
VIT-011911	Sun Nov 08, 2026 01:33 PM	map	89.0
VIT-011912	Sun Nov 08, 2026 01:33 PM	gcs	15.0
VIT-011871	Sun Nov 08, 2026 09:33 PM	spo2	92.0	nasal cannula
VIT-011872	Sun Nov 08, 2026 09:33 PM	rr	24.0
VIT-011873	Sun Nov 08, 2026 09:33 PM	o2_lpm	4.0	nasal cannula
VIT-011913	Sun Nov 08, 2026 09:33 PM	temp_c	37.3
VIT-011914	Sun Nov 08, 2026 09:33 PM	hr	81.0
VIT-011915	Sun Nov 08, 2026 09:33 PM	map	77.0
VIT-011916	Sun Nov 08, 2026 09:33 PM	gcs	15.0
VIT-011874	Mon Nov 09, 2026 05:33 AM	spo2	94.0	nasal cannula
VIT-011875	Mon Nov 09, 2026 05:33 AM	rr	24.0
VIT-011876	Mon Nov 09, 2026 05:33 AM	o2_lpm	2.0	nasal cannula
VIT-011917	Mon Nov 09, 2026 05:33 AM	temp_c	37.4
VIT-011918	Mon Nov 09, 2026 05:33 AM	hr	71.0
VIT-011919	Mon Nov 09, 2026 05:33 AM	map	92.0
VIT-011920	Mon Nov 09, 2026 05:33 AM	gcs	15.0

Medications, orders, echo, history (12)

MED-000478 11-05 22:13 cefepime per protocol IV
MED-000479 11-06 05:00 ceftriaxone per protocol IV
MED-000480 11-07 05:00 piperacillin-tazobactam per protocol IV
MED-000481 11-05 08:00 furosemide 40 mg IV
MED-000482 11-05 20:00 furosemide 40 mg IV
MED-000483 11-06 08:00 furosemide 40 mg IV
MED-000484 11-06 20:00 furosemide 40 mg IV
MED-000485 11-07 08:00 furosemide 40 mg IV
MED-000486 11-07 20:00 furosemide 40 mg IV
ORD-000102 11-05 21:43 blood_culture: blood cultures x2
ORD-000103 11-06 09:00 transfusion_prbc: transfuse PRBC
ECH-000059 2026-11-06 echo LVEF 21.0%

Notes

History and physical · DOC-000412 · Dr. Kenji Stavros (attending) · Fri Nov 06, 2026 12:13 AM

Cited facts from this note (3)

bleeding_source: bleeding from the surgical drain · cited p. 1, line 5 · confidence 0.85

Show source for bleeding_source

… 7-year-old man admitted with urinary tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime. Hospital course complicated by bleeding from the surgical drain. Past medical history: type 2 diabetes, hypertension, GERD. Review of systems otherwise negative. Exam: Lungs: increased work of breathing with accessory muscl …
infection_source: urinary tract infection · cited p. 1, line 5 · confidence 0.85

Show source for infection_source

… : MRN54136198 Admitted: 2026-11-05 21:13 Service: Hospital Medicine Attending: Dr. Kenji Stavros History of present illness: 47-year-old man admitted with urinary tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime. Hospital course complicated by bleeding from the surgical drain. Past medical histo …
work_of_breathing: increased · cited p. 1, line 8 · confidence 0.90

Show source for work_of_breathing

… complicated by bleeding from the surgical drain. Past medical history: type 2 diabetes, hypertension, GERD. Review of systems otherwise negative. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. Urinary tract infection: antibiotics.

Source document DOC-000412: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Bodhi Foxhall   MRN: MRN54136198   Admitted: 2026-11-05 21:13
Service: Hospital Medicine   Attending: Dr. Kenji Stavros

History of present illness: 47-year-old man admitted with urinary tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime. Hospital course complicated by bleeding from the surgical drain.
Past medical history: type 2 diabetes, hypertension, GERD.
Review of systems otherwise negative.
Exam: Lungs: increased work of breathing with accessory muscle use.
Assessment and plan:
1. Urinary tract infection: antibiotics.

Nutrition assessment · DOC-000411 · Dario Larkspur, RD (dietitian) · Fri Nov 06, 2026 11:13 PM

Cited facts from this note (8)

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

Show source for fat_loss

… Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets criteria for non-severe (moderate) malnutrition.
fluid_accumulation: none · cited p. 1, line 7 · confidence 0.90

Show source for fluid_accumulation

… ake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets criteria for non-severe (moderate) malnutrition.
intake_days: 11 · cited p. 1, line 5 · confidence 0.95

Show source for intake_days

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Bodhi Foxhall MRN: MRN54136198 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip …
intake_pct: 60 · cited p. 1, line 5 · confidence 0.95

Show source for intake_pct

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Bodhi Foxhall MRN: MRN54136198 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip …
muscle_loss: mild · cited p. 1, line 7 · confidence 0.90

Show source for muscle_loss

… estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets criteria for non-severe (moderate) malnutrition.
nutrition_context: acute · cited p. 1, line 4 · confidence 0.95

Show source for nutrition_context

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Bodhi Foxhall MRN: MRN54136198 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneo …
weight_loss_days: 30 · cited p. 1, line 6 · confidence 0.95

Show source for weight_loss_days

… gistered Dietitian) Patient: Bodhi Foxhall MRN: MRN54136198 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets cri …
weight_loss_pct: 3 · cited p. 1, line 6 · confidence 0.95

Show source for weight_loss_pct

… gistered Dietitian) Patient: Bodhi Foxhall MRN: MRN54136198 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets cri …

Source document DOC-000411: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Bodhi Foxhall   MRN: MRN54136198

Context: acute illness
Intake: estimated energy intake 60% of needs for 11 days.
Weight history: 3% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Grip strength: not assessed.
Assessment: meets criteria for non-severe (moderate) malnutrition.

Progress note · DOC-000413 · Dr. Kenji Stavros (attending) · Sat Nov 07, 2026 09:13 PM

Source document DOC-000413: Progress note (synthetic)

PROGRESS NOTE (Attending)
Patient: Bodhi Foxhall   MRN: MRN54136198   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Urinary tract infection: continue current management.
2. Severe malnutrition: dietitian following, supplements.
3. AKI: trend creatinine, hold nephrotoxins, strict intake and output.
4. Heart failure: diuresis and daily weights; monitor electrolytes.
5. Acute respiratory failure with hypoxia: supplemental oxygen, wean as tolerated.
6. Anemia: trend hemoglobin.

Attending: Dr. Kenji Stavros

Discharge summary · DOC-000414 · Dr. Kenji Stavros (attending) · Mon Nov 09, 2026 10:39 AM

Source document DOC-000414: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Bodhi Foxhall   MRN: MRN54136198
Admitted 2026-11-05; discharged 2026-11-09.

Discharge diagnoses:
- urinary tract infection
- severe malnutrition
- AKI
- heart failure
- acute respiratory failure with hypoxia
- anemia
- type 2 diabetes
- hypertension
- GERD

Disposition: home with follow-up.