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-00132: Lena Galloway

46F · MRN16511572 · Hospital Medicine · admitted Tue Nov 10, 2026 03:59 PM · in hospital · attending Dr. Jalen Carrow · resident Dr. Keira Upfield · 153 cm, 50.4 kg

Documented diagnoses (current)

Principal: “urinary tract infection” · N39.0 Urinary tract infection, site not specified
“hyperlipidemia” · E78.5 Hyperlipidemia, unspecified
“type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications
“hypertension” · I10 Essential (primary) hypertension

Illustrative grouping now: MS-DRG 690 Kidney and urinary tract infections without MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 690.

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=1.049, t.ratio_s1=1.5, creat_rise_48h=0.06, 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=1.049, t.ratio_s3=3.0, creat_peak=1.07, 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=1.049, 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=0.06, 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=F, hgb_nadir=12.47, 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=0.4, 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=False, acute_fall=False	false
outcome: anaemia_only	`anaemic and hgb_drop < t.drop_min and prbc_units == 0`	anaemic=False, hgb_drop=0.4, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=12.47, 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=294, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=69.5, egfr_late=68.7	69.5
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=69.5, t.g2=60, egfr_late=68.7	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=69.5, 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=69.5, egfr_late=68.7, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=69.5, 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 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=46, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=21.5, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=21.5, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=21.5, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=21.5, 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=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=19.0, 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=37.1, 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=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=19.0, 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=10.84, t.wbc_hi=12, wbc_min_48h=5.81, 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=191.0	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=0.81	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=80.0	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=1.07	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=1.02	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 (23)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-004503	Tue Nov 11, 2025 09:15 AM	creatinine	1.01 mg/dL
LAB-004504	Wed Sep 02, 2026 10:05 AM	creatinine	1.02 mg/dL
LAB-004505	Tue Nov 10, 2026 04:59 PM	creatinine	1.07 mg/dL
LAB-004509	Tue Nov 10, 2026 04:59 PM	sodium	138.0 mmol/L
LAB-004513	Tue Nov 10, 2026 04:59 PM	hemoglobin	12.52 g/dL
LAB-004517	Tue Nov 10, 2026 04:59 PM	wbc	9.1 x10^3/uL
LAB-004518	Tue Nov 10, 2026 04:59 PM	platelets	191.0 x10^3/uL
LAB-004525	Tue Nov 10, 2026 04:59 PM	bilirubin	0.81 mg/dL
LAB-004506	Wed Nov 11, 2026 05:00 AM	creatinine	1.01 mg/dL
LAB-004510	Wed Nov 11, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-004514	Wed Nov 11, 2026 05:00 AM	hemoglobin	12.85 g/dL
LAB-004519	Wed Nov 11, 2026 05:00 AM	wbc	10.84 x10^3/uL
LAB-004520	Wed Nov 11, 2026 05:00 AM	platelets	217.0 x10^3/uL
LAB-004507	Thu Nov 12, 2026 05:00 AM	creatinine	1.05 mg/dL
LAB-004511	Thu Nov 12, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-004515	Thu Nov 12, 2026 05:00 AM	hemoglobin	12.47 g/dL
LAB-004521	Thu Nov 12, 2026 05:00 AM	wbc	5.81 x10^3/uL
LAB-004522	Thu Nov 12, 2026 05:00 AM	platelets	299.0 x10^3/uL
LAB-004508	Fri Nov 13, 2026 05:00 AM	creatinine	1.07 mg/dL
LAB-004512	Fri Nov 13, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-004516	Fri Nov 13, 2026 05:00 AM	hemoglobin	12.74 g/dL
LAB-004523	Fri Nov 13, 2026 05:00 AM	wbc	8.85 x10^3/uL
LAB-004524	Fri Nov 13, 2026 05:00 AM	platelets	199.0 x10^3/uL

Vitals (60)

Vitals
Row	When	Kind	Value	Detail
VIT-012933	Tue Nov 10, 2026 04:19 PM	spo2	95.0	room air
VIT-012934	Tue Nov 10, 2026 04:19 PM	rr	18.0
VIT-012953	Tue Nov 10, 2026 04:19 PM	temp_c	36.7
VIT-012954	Tue Nov 10, 2026 04:19 PM	hr	70.0
VIT-012955	Tue Nov 10, 2026 04:19 PM	map	80.0
VIT-012956	Tue Nov 10, 2026 04:19 PM	gcs	15.0
VIT-012935	Wed Nov 11, 2026 12:19 AM	spo2	97.0	room air
VIT-012936	Wed Nov 11, 2026 12:19 AM	rr	19.0
VIT-012957	Wed Nov 11, 2026 12:19 AM	temp_c	36.7
VIT-012958	Wed Nov 11, 2026 12:19 AM	hr	77.0
VIT-012959	Wed Nov 11, 2026 12:19 AM	map	85.0
VIT-012960	Wed Nov 11, 2026 12:19 AM	gcs	15.0
VIT-012937	Wed Nov 11, 2026 08:19 AM	spo2	98.0	room air
VIT-012938	Wed Nov 11, 2026 08:19 AM	rr	15.0
VIT-012961	Wed Nov 11, 2026 08:19 AM	temp_c	36.6
VIT-012962	Wed Nov 11, 2026 08:19 AM	hr	84.0
VIT-012963	Wed Nov 11, 2026 08:19 AM	map	80.0
VIT-012964	Wed Nov 11, 2026 08:19 AM	gcs	15.0
VIT-012939	Wed Nov 11, 2026 04:19 PM	spo2	95.0	room air
VIT-012940	Wed Nov 11, 2026 04:19 PM	rr	14.0
VIT-012965	Wed Nov 11, 2026 04:19 PM	temp_c	37.1
VIT-012966	Wed Nov 11, 2026 04:19 PM	hr	74.0
VIT-012967	Wed Nov 11, 2026 04:19 PM	map	85.0
VIT-012968	Wed Nov 11, 2026 04:19 PM	gcs	15.0
VIT-012941	Thu Nov 12, 2026 12:19 AM	spo2	97.0	room air
VIT-012942	Thu Nov 12, 2026 12:19 AM	rr	15.0
VIT-012969	Thu Nov 12, 2026 12:19 AM	temp_c	36.8
VIT-012970	Thu Nov 12, 2026 12:19 AM	hr	85.0
VIT-012971	Thu Nov 12, 2026 12:19 AM	map	82.0
VIT-012972	Thu Nov 12, 2026 12:19 AM	gcs	15.0
VIT-012943	Thu Nov 12, 2026 08:19 AM	spo2	97.0	room air
VIT-012944	Thu Nov 12, 2026 08:19 AM	rr	14.0
VIT-012973	Thu Nov 12, 2026 08:19 AM	temp_c	36.9
VIT-012974	Thu Nov 12, 2026 08:19 AM	hr	86.0
VIT-012975	Thu Nov 12, 2026 08:19 AM	map	86.0
VIT-012976	Thu Nov 12, 2026 08:19 AM	gcs	15.0
VIT-012945	Thu Nov 12, 2026 04:19 PM	spo2	97.0	room air
VIT-012946	Thu Nov 12, 2026 04:19 PM	rr	19.0
VIT-012977	Thu Nov 12, 2026 04:19 PM	temp_c	36.8
VIT-012978	Thu Nov 12, 2026 04:19 PM	hr	77.0
VIT-012979	Thu Nov 12, 2026 04:19 PM	map	78.0
VIT-012980	Thu Nov 12, 2026 04:19 PM	gcs	15.0
VIT-012947	Fri Nov 13, 2026 12:19 AM	spo2	98.0	room air
VIT-012948	Fri Nov 13, 2026 12:19 AM	rr	19.0
VIT-012981	Fri Nov 13, 2026 12:19 AM	temp_c	37.6
VIT-012982	Fri Nov 13, 2026 12:19 AM	hr	74.0
VIT-012983	Fri Nov 13, 2026 12:19 AM	map	76.0
VIT-012984	Fri Nov 13, 2026 12:19 AM	gcs	15.0
VIT-012949	Fri Nov 13, 2026 08:19 AM	spo2	97.0	room air
VIT-012950	Fri Nov 13, 2026 08:19 AM	rr	17.0
VIT-012985	Fri Nov 13, 2026 08:19 AM	temp_c	37.5
VIT-012986	Fri Nov 13, 2026 08:19 AM	hr	90.0
VIT-012987	Fri Nov 13, 2026 08:19 AM	map	83.0
VIT-012988	Fri Nov 13, 2026 08:19 AM	gcs	15.0
VIT-012951	Fri Nov 13, 2026 04:19 PM	spo2	99.0	room air
VIT-012952	Fri Nov 13, 2026 04:19 PM	rr	14.0
VIT-012989	Fri Nov 13, 2026 04:19 PM	temp_c	36.8
VIT-012990	Fri Nov 13, 2026 04:19 PM	hr	73.0
VIT-012991	Fri Nov 13, 2026 04:19 PM	map	91.0
VIT-012992	Fri Nov 13, 2026 04:19 PM	gcs	15.0

Medications, orders, echo, history (4)

MED-000516 11-10 16:59 piperacillin-tazobactam per protocol IV
MED-000517 11-11 05:00 ceftriaxone per protocol IV
MED-000518 11-12 05:00 ceftriaxone per protocol IV
ORD-000115 11-10 16:29 blood_culture: blood cultures x2

Notes

History and physical · DOC-000446 · Dr. Keira Upfield (resident) · Tue Nov 10, 2026 06:59 PM

Cited facts from this note (1)

infection_source: urinary tract infection · cited p. 1, line 5 · confidence 0.85

Show source for infection_source

… MRN16511572 Admitted: 2026-11-10 15:59 Service: Hospital Medicine Attending: Dr. Jalen Carrow History of present illness: 46-year-old woman admitted with urinary tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime. Past medical history: hyperlipidemia, type 2 diabetes, hypertension. Review of syst …

Source document DOC-000446: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Lena Galloway   MRN: MRN16511572   Admitted: 2026-11-10 15:59
Service: Hospital Medicine   Attending: Dr. Jalen Carrow

History of present illness: 46-year-old woman admitted with urinary tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime.
Past medical history: hyperlipidemia, type 2 diabetes, hypertension.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Urinary tract infection: antibiotics.

Nutrition assessment · DOC-000445 · Dario Larkspur, RD (dietitian) · Wed Nov 11, 2026 07:59 PM

Cited facts from this note (5)

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

Show source for fat_loss

… MRN: MRN16511572 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: Lena Galloway MRN: MRN16511572 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: Lena Galloway MRN: MRN16511572 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-000445: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Lena Galloway   MRN: MRN16511572

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-000447 · Dr. Keira Upfield (resident) · Fri Nov 13, 2026 11:55 AM · awaiting cosign

Source document DOC-000447: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Lena Galloway   MRN: MRN16511572   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.

Resident: Dr. Keira Upfield   Attending cosign: pending