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-00126: Yusuf Pemberton

63M · MRN26877064 · Hospital Medicine · admitted Thu Nov 05, 2026 02:37 PM · discharged Tue Nov 10, 2026 11:27 AM · attending Dr. Gideon Zeller · resident Dr. Noor Halvorsen · 176 cm, 64.0 kg

Documented diagnoses (current)

Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“severe malnutrition” · E43 Unspecified severe protein-calorie malnutrition
“hyperlipidemia” · E78.5 Hyperlipidemia, unspecified

Illustrative grouping now: MS-DRG 193 Simple pneumonia and pleurisy with MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 193.

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=1.031, t.ratio_s1=1.5, creat_rise_48h=0.02, 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=1.031, t.ratio_s3=3.0, creat_peak=1.0, 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=1.031, 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=0.02, 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 not met

No gap

Not documented and not supported.

Trace

Rule trace (rule blood_loss_anemia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: anaemic	`case(sex == 'M', hgb_nadir < t.hb_m, sex == 'F', hgb_nadir < t.hb_f, null)`	sex=M, hgb_nadir=13.44, t.hb_m=13, t.hb_f=12	false
derived: acute_fall	`hgb_drop >= t.drop_major or prbc_units >= t.prbc_major`	hgb_drop=0.3, t.drop_major=2.0, prbc_units=0, t.prbc_major=2	false
outcome: met	`bleeding_documented and anaemic and acute_fall`	bleeding_documented=False, anaemic=False, acute_fall=False	false
outcome: anaemia_only	`anaemic and hgb_drop < t.drop_min and prbc_units == 0`	anaemic=False, hgb_drop=0.3, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=13.44, anaemic=False	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=258, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=86.6, egfr_late=87.7	87.7
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=86.6, t.g2=60, egfr_late=87.7	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=87.7, 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=86.6, egfr_late=87.7, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=87.7, t.g2=60	true

Heart failure

Clinical judgement required

No gap

Not documented; only one acute indicator; acuity needs clinical judgement.

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=True	1
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=1, 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=1	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=139.0, 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=139.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=139.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=139.0, 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=12.0, 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=12.0, 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=12.0, 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=12.0, 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=63, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=20.7, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=20.7, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=20.7, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=20.7, 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

Specificity gap

Criteria support Acute respiratory failure with hypoxia (J96.01); no corresponding diagnosis is documented.

Trace

Rule trace (rule respiratory_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: measured	`present(spo2_min_ra) or present(pao2_min_ra) or present(pf_min)`	spo2_min_ra=86.0, pao2_min_ra=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=86.0, t.spo2_ra=88, pao2_min_ra=unknown, t.pao2=60, pf_min=unknown, t.pf=300	true
derived: distress	`coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support`	rr_max=30.0, t.rr_distress=28, wob_increased=unknown, 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 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=36.7, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=86.0, 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=30.0, 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=8.91, t.wbc_hi=12, wbc_min_48h=6.75, 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=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=209.0	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=0.9	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=79.0	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=1.0	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=0.97	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=1, 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-004263	Fri Nov 28, 2025 09:15 AM	creatinine	0.98 mg/dL
LAB-004264	Fri Aug 14, 2026 10:05 AM	creatinine	0.97 mg/dL
LAB-004265	Thu Nov 05, 2026 03:37 PM	creatinine	1.0 mg/dL
LAB-004271	Thu Nov 05, 2026 03:37 PM	sodium	141.0 mmol/L
LAB-004277	Thu Nov 05, 2026 03:37 PM	hemoglobin	13.71 g/dL
LAB-004283	Thu Nov 05, 2026 03:37 PM	wbc	6.75 x10^3/uL
LAB-004284	Thu Nov 05, 2026 03:37 PM	platelets	209.0 x10^3/uL
LAB-004295	Thu Nov 05, 2026 03:37 PM	bilirubin	0.9 mg/dL
LAB-004266	Fri Nov 06, 2026 05:00 AM	creatinine	0.99 mg/dL
LAB-004272	Fri Nov 06, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-004278	Fri Nov 06, 2026 05:00 AM	hemoglobin	13.56 g/dL
LAB-004285	Fri Nov 06, 2026 05:00 AM	wbc	8.91 x10^3/uL
LAB-004286	Fri Nov 06, 2026 05:00 AM	platelets	255.0 x10^3/uL
LAB-004267	Sat Nov 07, 2026 05:00 AM	creatinine	0.97 mg/dL
LAB-004273	Sat Nov 07, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-004279	Sat Nov 07, 2026 05:00 AM	hemoglobin	13.45 g/dL
LAB-004287	Sat Nov 07, 2026 05:00 AM	wbc	8.34 x10^3/uL
LAB-004288	Sat Nov 07, 2026 05:00 AM	platelets	267.0 x10^3/uL
LAB-004268	Sun Nov 08, 2026 05:00 AM	creatinine	0.98 mg/dL
LAB-004274	Sun Nov 08, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-004280	Sun Nov 08, 2026 05:00 AM	hemoglobin	13.44 g/dL
LAB-004289	Sun Nov 08, 2026 05:00 AM	wbc	10.76 x10^3/uL
LAB-004290	Sun Nov 08, 2026 05:00 AM	platelets	181.0 x10^3/uL
LAB-004269	Mon Nov 09, 2026 05:00 AM	creatinine	0.99 mg/dL
LAB-004275	Mon Nov 09, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-004281	Mon Nov 09, 2026 05:00 AM	hemoglobin	13.83 g/dL
LAB-004291	Mon Nov 09, 2026 05:00 AM	wbc	10.23 x10^3/uL
LAB-004292	Mon Nov 09, 2026 05:00 AM	platelets	302.0 x10^3/uL
LAB-004270	Tue Nov 10, 2026 05:00 AM	creatinine	0.98 mg/dL
LAB-004276	Tue Nov 10, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-004282	Tue Nov 10, 2026 05:00 AM	hemoglobin	13.59 g/dL
LAB-004293	Tue Nov 10, 2026 05:00 AM	wbc	7.04 x10^3/uL
LAB-004294	Tue Nov 10, 2026 05:00 AM	platelets	184.0 x10^3/uL

Vitals (105)

Vitals
Row	When	Kind	Value	Detail
VIT-012224	Thu Nov 05, 2026 02:57 PM	spo2	86.0	room air
VIT-012225	Thu Nov 05, 2026 02:57 PM	rr	30.0
VIT-012269	Thu Nov 05, 2026 02:57 PM	temp_c	36.8
VIT-012270	Thu Nov 05, 2026 02:57 PM	hr	70.0
VIT-012271	Thu Nov 05, 2026 02:57 PM	map	79.0
VIT-012272	Thu Nov 05, 2026 02:57 PM	gcs	15.0
VIT-012226	Thu Nov 05, 2026 03:07 PM	o2_lpm	4.0	nasal cannula
VIT-012227	Thu Nov 05, 2026 10:57 PM	spo2	92.0	nasal cannula
VIT-012228	Thu Nov 05, 2026 10:57 PM	rr	26.0
VIT-012229	Thu Nov 05, 2026 10:57 PM	o2_lpm	4.0	nasal cannula
VIT-012273	Thu Nov 05, 2026 10:57 PM	temp_c	37.4
VIT-012274	Thu Nov 05, 2026 10:57 PM	hr	86.0
VIT-012275	Thu Nov 05, 2026 10:57 PM	map	87.0
VIT-012276	Thu Nov 05, 2026 10:57 PM	gcs	15.0
VIT-012230	Fri Nov 06, 2026 06:57 AM	spo2	94.0	nasal cannula
VIT-012231	Fri Nov 06, 2026 06:57 AM	rr	21.0
VIT-012232	Fri Nov 06, 2026 06:57 AM	o2_lpm	4.0	nasal cannula
VIT-012277	Fri Nov 06, 2026 06:57 AM	temp_c	37.4
VIT-012278	Fri Nov 06, 2026 06:57 AM	hr	79.0
VIT-012279	Fri Nov 06, 2026 06:57 AM	map	85.0
VIT-012280	Fri Nov 06, 2026 06:57 AM	gcs	15.0
VIT-012233	Fri Nov 06, 2026 02:57 PM	spo2	92.0	nasal cannula
VIT-012234	Fri Nov 06, 2026 02:57 PM	rr	23.0
VIT-012235	Fri Nov 06, 2026 02:57 PM	o2_lpm	4.0	nasal cannula
VIT-012281	Fri Nov 06, 2026 02:57 PM	temp_c	37.6
VIT-012282	Fri Nov 06, 2026 02:57 PM	hr	74.0
VIT-012283	Fri Nov 06, 2026 02:57 PM	map	87.0
VIT-012284	Fri Nov 06, 2026 02:57 PM	gcs	15.0
VIT-012236	Fri Nov 06, 2026 10:57 PM	spo2	95.0	nasal cannula
VIT-012237	Fri Nov 06, 2026 10:57 PM	rr	24.0
VIT-012238	Fri Nov 06, 2026 10:57 PM	o2_lpm	4.0	nasal cannula
VIT-012285	Fri Nov 06, 2026 10:57 PM	temp_c	37.1
VIT-012286	Fri Nov 06, 2026 10:57 PM	hr	86.0
VIT-012287	Fri Nov 06, 2026 10:57 PM	map	80.0
VIT-012288	Fri Nov 06, 2026 10:57 PM	gcs	15.0
VIT-012239	Sat Nov 07, 2026 06:57 AM	spo2	92.0	nasal cannula
VIT-012240	Sat Nov 07, 2026 06:57 AM	rr	23.0
VIT-012241	Sat Nov 07, 2026 06:57 AM	o2_lpm	2.0	nasal cannula
VIT-012289	Sat Nov 07, 2026 06:57 AM	temp_c	36.7
VIT-012290	Sat Nov 07, 2026 06:57 AM	hr	74.0
VIT-012291	Sat Nov 07, 2026 06:57 AM	map	89.0
VIT-012292	Sat Nov 07, 2026 06:57 AM	gcs	15.0
VIT-012242	Sat Nov 07, 2026 02:57 PM	spo2	94.0	nasal cannula
VIT-012243	Sat Nov 07, 2026 02:57 PM	rr	24.0
VIT-012244	Sat Nov 07, 2026 02:57 PM	o2_lpm	4.0	nasal cannula
VIT-012293	Sat Nov 07, 2026 02:57 PM	temp_c	37.5
VIT-012294	Sat Nov 07, 2026 02:57 PM	hr	72.0
VIT-012295	Sat Nov 07, 2026 02:57 PM	map	78.0
VIT-012296	Sat Nov 07, 2026 02:57 PM	gcs	15.0
VIT-012245	Sat Nov 07, 2026 10:57 PM	spo2	91.0	nasal cannula
VIT-012246	Sat Nov 07, 2026 10:57 PM	rr	24.0
VIT-012247	Sat Nov 07, 2026 10:57 PM	o2_lpm	2.0	nasal cannula
VIT-012297	Sat Nov 07, 2026 10:57 PM	temp_c	37.2
VIT-012298	Sat Nov 07, 2026 10:57 PM	hr	90.0
VIT-012299	Sat Nov 07, 2026 10:57 PM	map	76.0
VIT-012300	Sat Nov 07, 2026 10:57 PM	gcs	15.0
VIT-012248	Sun Nov 08, 2026 06:57 AM	spo2	92.0	nasal cannula
VIT-012249	Sun Nov 08, 2026 06:57 AM	rr	23.0
VIT-012250	Sun Nov 08, 2026 06:57 AM	o2_lpm	3.0	nasal cannula
VIT-012301	Sun Nov 08, 2026 06:57 AM	temp_c	36.7
VIT-012302	Sun Nov 08, 2026 06:57 AM	hr	76.0
VIT-012303	Sun Nov 08, 2026 06:57 AM	map	78.0
VIT-012304	Sun Nov 08, 2026 06:57 AM	gcs	15.0
VIT-012251	Sun Nov 08, 2026 02:57 PM	spo2	95.0	nasal cannula
VIT-012252	Sun Nov 08, 2026 02:57 PM	rr	21.0
VIT-012253	Sun Nov 08, 2026 02:57 PM	o2_lpm	4.0	nasal cannula
VIT-012305	Sun Nov 08, 2026 02:57 PM	temp_c	36.6
VIT-012306	Sun Nov 08, 2026 02:57 PM	hr	74.0
VIT-012307	Sun Nov 08, 2026 02:57 PM	map	88.0
VIT-012308	Sun Nov 08, 2026 02:57 PM	gcs	15.0
VIT-012254	Sun Nov 08, 2026 10:57 PM	spo2	93.0	nasal cannula
VIT-012255	Sun Nov 08, 2026 10:57 PM	rr	20.0
VIT-012256	Sun Nov 08, 2026 10:57 PM	o2_lpm	3.0	nasal cannula
VIT-012309	Sun Nov 08, 2026 10:57 PM	temp_c	36.9
VIT-012310	Sun Nov 08, 2026 10:57 PM	hr	75.0
VIT-012311	Sun Nov 08, 2026 10:57 PM	map	79.0
VIT-012312	Sun Nov 08, 2026 10:57 PM	gcs	15.0
VIT-012257	Mon Nov 09, 2026 06:57 AM	spo2	91.0	nasal cannula
VIT-012258	Mon Nov 09, 2026 06:57 AM	rr	20.0
VIT-012259	Mon Nov 09, 2026 06:57 AM	o2_lpm	2.0	nasal cannula
VIT-012313	Mon Nov 09, 2026 06:57 AM	temp_c	37.1
VIT-012314	Mon Nov 09, 2026 06:57 AM	hr	89.0
VIT-012315	Mon Nov 09, 2026 06:57 AM	map	92.0
VIT-012316	Mon Nov 09, 2026 06:57 AM	gcs	15.0
VIT-012260	Mon Nov 09, 2026 02:57 PM	spo2	91.0	nasal cannula
VIT-012261	Mon Nov 09, 2026 02:57 PM	rr	23.0
VIT-012262	Mon Nov 09, 2026 02:57 PM	o2_lpm	4.0	nasal cannula
VIT-012317	Mon Nov 09, 2026 02:57 PM	temp_c	36.7
VIT-012318	Mon Nov 09, 2026 02:57 PM	hr	75.0
VIT-012319	Mon Nov 09, 2026 02:57 PM	map	82.0
VIT-012320	Mon Nov 09, 2026 02:57 PM	gcs	15.0
VIT-012263	Mon Nov 09, 2026 10:57 PM	spo2	93.0	nasal cannula
VIT-012264	Mon Nov 09, 2026 10:57 PM	rr	25.0
VIT-012265	Mon Nov 09, 2026 10:57 PM	o2_lpm	4.0	nasal cannula
VIT-012321	Mon Nov 09, 2026 10:57 PM	temp_c	37.4
VIT-012322	Mon Nov 09, 2026 10:57 PM	hr	68.0
VIT-012323	Mon Nov 09, 2026 10:57 PM	map	82.0
VIT-012324	Mon Nov 09, 2026 10:57 PM	gcs	15.0
VIT-012266	Tue Nov 10, 2026 06:57 AM	spo2	94.0	nasal cannula
VIT-012267	Tue Nov 10, 2026 06:57 AM	rr	20.0
VIT-012268	Tue Nov 10, 2026 06:57 AM	o2_lpm	2.0	nasal cannula
VIT-012325	Tue Nov 10, 2026 06:57 AM	temp_c	37.3
VIT-012326	Tue Nov 10, 2026 06:57 AM	hr	71.0
VIT-012327	Tue Nov 10, 2026 06:57 AM	map	84.0
VIT-012328	Tue Nov 10, 2026 06:57 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000497 11-05 15:37 piperacillin-tazobactam per protocol IV
MED-000498 11-06 05:00 ceftriaxone per protocol IV
MED-000499 11-07 05:00 piperacillin-tazobactam per protocol IV
ORD-000106 11-05 15:07 blood_culture: blood cultures x2

Notes

History and physical · DOC-000426 · Dr. Noor Halvorsen (resident) · Thu Nov 05, 2026 05:37 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: 63-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: hyperlipidemia. Review of systems otherwise negative. Exam: Lungs: labored respirations. A …

Source document DOC-000426: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Yusuf Pemberton   MRN: MRN26877064   Admitted: 2026-11-05 14:37
Service: Hospital Medicine   Attending: Dr. Gideon Zeller

History of present illness: 63-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: hyperlipidemia.
Review of systems otherwise negative.
Exam: Lungs: labored respirations.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Nutrition assessment · DOC-000425 · Vera Pemberton, RD (dietitian) · Fri Nov 06, 2026 05:37 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 12 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 12 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: 12 · cited p. 1, line 5 · confidence 0.95

Show source for intake_days

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Yusuf Pemberton MRN: MRN26877064 Context: acute illness Intake: estimated energy intake 60% of needs for 12 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: Yusuf Pemberton MRN: MRN26877064 Context: acute illness Intake: estimated energy intake 60% of needs for 12 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 12 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: Yusuf Pemberton MRN: MRN26877064 Context: acute illness Intake: estimated energy intake 60% of needs for 12 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

… stered Dietitian) Patient: Yusuf Pemberton MRN: MRN26877064 Context: acute illness Intake: estimated energy intake 60% of needs for 12 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

… stered Dietitian) Patient: Yusuf Pemberton MRN: MRN26877064 Context: acute illness Intake: estimated energy intake 60% of needs for 12 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-000425: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Yusuf Pemberton   MRN: MRN26877064

Context: acute illness
Intake: estimated energy intake 60% of needs for 12 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-000427 · Dr. Noor Halvorsen (resident) · Sat Nov 07, 2026 05:37 PM

Source document DOC-000427: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Yusuf Pemberton   MRN: MRN26877064   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. Severe malnutrition: dietitian following, supplements.

Resident: Dr. Noor Halvorsen   Attending cosign: completed

Discharge summary · DOC-000428 · Dr. Gideon Zeller (attending) · Tue Nov 10, 2026 11:27 AM

Source document DOC-000428: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Yusuf Pemberton   MRN: MRN26877064
Admitted 2026-11-05; discharged 2026-11-10.

Discharge diagnoses:
- community-acquired pneumonia
- severe malnutrition
- hyperlipidemia

Disposition: home with follow-up.