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-00138: Amara Greaves

68M · MRN89238449 · Hospital Medicine · admitted Thu Nov 05, 2026 08:33 AM · discharged Sun Nov 08, 2026 04:58 PM · attending Dr. Kenji Stavros · resident Dr. Priya Thorne · 182 cm, 66.0 kg

Documented diagnoses (current)

Principal: “sepsis” · A41.9 Sepsis, unspecified organism
“community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“AKI” · N17.9 Acute kidney failure, unspecified
“hypoxemia” · R09.02 Hypoxemia

Illustrative grouping now: MS-DRG 871 Septicemia or severe sepsis without MV >96 hours with MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 871.

Queries and events

No queries yet.

All rules applied

Rule Criteria Finding Outcome

Acute kidney injury

Criteria met

No gap

Supported as documented (N17.9).

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=1.613, t.ratio_s1=1.5, creat_rise_48h=0.39, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, t.uo_s1_h=6	true
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=True, creat_ratio=1.613, t.ratio_s3=3.0, creat_peak=1.79, 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=1.613, 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=True	1
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=0.39, t.rise_abs=0.3, rrt_started=False	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	stage=1, baseline_independent=True	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=14.65, 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=14.65, 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=334, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=73.1, egfr_late=72.3	73.1
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=73.1, t.g2=60, egfr_late=72.3	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=73.1, 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=73.1, egfr_late=72.3, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=73.1, 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=136.0, 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=136.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=136.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=136.0, t.low=135	true

Malnutrition

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

Trace

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

Obesity

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule obesity v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
outcome: not_adult	`age < t.adult`	age=68, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=19.9, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=19.9, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=19.9, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=19.9, 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

Documented “hypoxemia” (R09.02); criteria support the more specific Acute respiratory failure with hypoxia (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=84.0, pao2_min_ra=52.0, pf_min=248	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=84.0, t.spo2_ra=88, pao2_min_ra=52.0, t.pao2=60, pf_min=248, t.pf=300	true
derived: distress	`coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support`	rr_max=28.0, 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

Supported as documented (A41.9).

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=39.2, t.t_hi=38, temp_min_48h=38.8, t.t_lo=36	true
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=120.0, t.hr=90	true
derived: sirs_rr	`coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false)`	rr_max_48h=28.0, 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=18.25, t.wbc_hi=12, wbc_min_48h=15.5, t.wbc_lo=4, bands_max_48h=unknown, t.bands=10	true
derived: sirs_count	`count(sirs_temp, sirs_hr, sirs_rr, sirs_wbc)`	sirs_temp=True, sirs_hr=True, sirs_rr=True, sirs_wbc=True	4
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=248, 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=82.0	2
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=0.85	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=65.0	1
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=1.79	1
derived: sofa_renal_baseline	`coalesce(case(creat_baseline >= 5, 4, creat_baseline >= 3.5, 3, creat_baseline >= 2, 2, creat_baseline >= 1.2, 1, 0), 0)`	creat_baseline=1.11	0
derived: sofa_delta	`sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline`	sofa_resp=2, sofa_coag=2, sofa_liver=0, sofa_cardio=1, sofa_cns=0, sofa_renal=1, sofa_renal_baseline=0	6
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=6, t.sofa_delta=2	true
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=True, sirs_count=4, t.sirs_min=2	true
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=2.92, 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=True	true

Structured data

Labs (26)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-004703	Sat Oct 04, 2025 09:15 AM	creatinine	1.1 mg/dL
LAB-004704	Thu Sep 03, 2026 10:05 AM	creatinine	1.11 mg/dL
LAB-004709	Thu Nov 05, 2026 08:58 AM	pao2	52.0 mmHg
LAB-004710	Thu Nov 05, 2026 08:58 AM	fio2	21.0 %
LAB-004705	Thu Nov 05, 2026 09:33 AM	creatinine	1.4 mg/dL
LAB-004711	Thu Nov 05, 2026 09:33 AM	sodium	141.0 mmol/L
LAB-004715	Thu Nov 05, 2026 09:33 AM	hemoglobin	14.99 g/dL
LAB-004719	Thu Nov 05, 2026 09:33 AM	wbc	18.25 x10^3/uL
LAB-004720	Thu Nov 05, 2026 09:33 AM	platelets	82.0 x10^3/uL
LAB-004727	Thu Nov 05, 2026 09:33 AM	bilirubin	0.85 mg/dL
LAB-004728	Thu Nov 05, 2026 09:33 AM	lactate	2.92 mmol/L
LAB-004706	Fri Nov 06, 2026 05:00 AM	creatinine	1.79 mg/dL
LAB-004712	Fri Nov 06, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-004716	Fri Nov 06, 2026 05:00 AM	hemoglobin	14.65 g/dL
LAB-004721	Fri Nov 06, 2026 05:00 AM	wbc	15.5 x10^3/uL
LAB-004722	Fri Nov 06, 2026 05:00 AM	platelets	89.0 x10^3/uL
LAB-004707	Sat Nov 07, 2026 05:00 AM	creatinine	1.61 mg/dL
LAB-004713	Sat Nov 07, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-004717	Sat Nov 07, 2026 05:00 AM	hemoglobin	14.85 g/dL
LAB-004723	Sat Nov 07, 2026 05:00 AM	wbc	17.48 x10^3/uL
LAB-004724	Sat Nov 07, 2026 05:00 AM	platelets	90.0 x10^3/uL
LAB-004708	Sun Nov 08, 2026 05:00 AM	creatinine	1.35 mg/dL
LAB-004714	Sun Nov 08, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-004718	Sun Nov 08, 2026 05:00 AM	hemoglobin	14.79 g/dL
LAB-004725	Sun Nov 08, 2026 05:00 AM	wbc	10.66 x10^3/uL
LAB-004726	Sun Nov 08, 2026 05:00 AM	platelets	259.0 x10^3/uL

Vitals (77)

Vitals
Row	When	Kind	Value	Detail
VIT-013512	Thu Nov 05, 2026 08:53 AM	spo2	84.0	room air
VIT-013513	Thu Nov 05, 2026 08:53 AM	rr	28.0
VIT-013545	Thu Nov 05, 2026 08:53 AM	temp_c	39.2
VIT-013546	Thu Nov 05, 2026 08:53 AM	hr	119.0
VIT-013547	Thu Nov 05, 2026 08:53 AM	map	66.0
VIT-013548	Thu Nov 05, 2026 08:53 AM	gcs	15.0
VIT-013514	Thu Nov 05, 2026 09:03 AM	o2_lpm	4.0	nasal cannula
VIT-013515	Thu Nov 05, 2026 04:53 PM	spo2	95.0	nasal cannula
VIT-013516	Thu Nov 05, 2026 04:53 PM	rr	20.0
VIT-013517	Thu Nov 05, 2026 04:53 PM	o2_lpm	3.0	nasal cannula
VIT-013549	Thu Nov 05, 2026 04:53 PM	temp_c	39.0
VIT-013550	Thu Nov 05, 2026 04:53 PM	hr	120.0
VIT-013551	Thu Nov 05, 2026 04:53 PM	map	65.0
VIT-013552	Thu Nov 05, 2026 04:53 PM	gcs	15.0
VIT-013518	Fri Nov 06, 2026 12:53 AM	spo2	92.0	nasal cannula
VIT-013519	Fri Nov 06, 2026 12:53 AM	rr	23.0
VIT-013520	Fri Nov 06, 2026 12:53 AM	o2_lpm	3.0	nasal cannula
VIT-013553	Fri Nov 06, 2026 12:53 AM	temp_c	38.8
VIT-013554	Fri Nov 06, 2026 12:53 AM	hr	114.0
VIT-013555	Fri Nov 06, 2026 12:53 AM	map	66.0
VIT-013556	Fri Nov 06, 2026 12:53 AM	gcs	15.0
VIT-013521	Fri Nov 06, 2026 08:53 AM	spo2	95.0	nasal cannula
VIT-013522	Fri Nov 06, 2026 08:53 AM	rr	21.0
VIT-013523	Fri Nov 06, 2026 08:53 AM	o2_lpm	3.0	nasal cannula
VIT-013557	Fri Nov 06, 2026 08:53 AM	temp_c	39.2
VIT-013558	Fri Nov 06, 2026 08:53 AM	hr	115.0
VIT-013559	Fri Nov 06, 2026 08:53 AM	map	68.0
VIT-013560	Fri Nov 06, 2026 08:53 AM	gcs	15.0
VIT-013524	Fri Nov 06, 2026 04:53 PM	spo2	92.0	nasal cannula
VIT-013525	Fri Nov 06, 2026 04:53 PM	rr	22.0
VIT-013526	Fri Nov 06, 2026 04:53 PM	o2_lpm	3.0	nasal cannula
VIT-013561	Fri Nov 06, 2026 04:53 PM	temp_c	39.1
VIT-013562	Fri Nov 06, 2026 04:53 PM	hr	108.0
VIT-013563	Fri Nov 06, 2026 04:53 PM	map	67.0
VIT-013564	Fri Nov 06, 2026 04:53 PM	gcs	15.0
VIT-013527	Sat Nov 07, 2026 12:53 AM	spo2	94.0	nasal cannula
VIT-013528	Sat Nov 07, 2026 12:53 AM	rr	20.0
VIT-013529	Sat Nov 07, 2026 12:53 AM	o2_lpm	3.0	nasal cannula
VIT-013565	Sat Nov 07, 2026 12:53 AM	temp_c	39.0
VIT-013566	Sat Nov 07, 2026 12:53 AM	hr	109.0
VIT-013567	Sat Nov 07, 2026 12:53 AM	map	67.0
VIT-013568	Sat Nov 07, 2026 12:53 AM	gcs	15.0
VIT-013530	Sat Nov 07, 2026 08:53 AM	spo2	92.0	nasal cannula
VIT-013531	Sat Nov 07, 2026 08:53 AM	rr	23.0
VIT-013532	Sat Nov 07, 2026 08:53 AM	o2_lpm	2.0	nasal cannula
VIT-013569	Sat Nov 07, 2026 08:53 AM	temp_c	37.0
VIT-013570	Sat Nov 07, 2026 08:53 AM	hr	70.0
VIT-013571	Sat Nov 07, 2026 08:53 AM	map	87.0
VIT-013572	Sat Nov 07, 2026 08:53 AM	gcs	15.0
VIT-013533	Sat Nov 07, 2026 04:53 PM	spo2	95.0	nasal cannula
VIT-013534	Sat Nov 07, 2026 04:53 PM	rr	26.0
VIT-013535	Sat Nov 07, 2026 04:53 PM	o2_lpm	2.0	nasal cannula
VIT-013573	Sat Nov 07, 2026 04:53 PM	temp_c	36.6
VIT-013574	Sat Nov 07, 2026 04:53 PM	hr	74.0
VIT-013575	Sat Nov 07, 2026 04:53 PM	map	79.0
VIT-013576	Sat Nov 07, 2026 04:53 PM	gcs	15.0
VIT-013536	Sun Nov 08, 2026 12:53 AM	spo2	92.0	nasal cannula
VIT-013537	Sun Nov 08, 2026 12:53 AM	rr	26.0
VIT-013538	Sun Nov 08, 2026 12:53 AM	o2_lpm	3.0	nasal cannula
VIT-013577	Sun Nov 08, 2026 12:53 AM	temp_c	37.6
VIT-013578	Sun Nov 08, 2026 12:53 AM	hr	69.0
VIT-013579	Sun Nov 08, 2026 12:53 AM	map	74.0
VIT-013580	Sun Nov 08, 2026 12:53 AM	gcs	15.0
VIT-013539	Sun Nov 08, 2026 08:53 AM	spo2	91.0	nasal cannula
VIT-013540	Sun Nov 08, 2026 08:53 AM	rr	22.0
VIT-013541	Sun Nov 08, 2026 08:53 AM	o2_lpm	3.0	nasal cannula
VIT-013581	Sun Nov 08, 2026 08:53 AM	temp_c	37.4
VIT-013582	Sun Nov 08, 2026 08:53 AM	hr	76.0
VIT-013583	Sun Nov 08, 2026 08:53 AM	map	80.0
VIT-013584	Sun Nov 08, 2026 08:53 AM	gcs	15.0
VIT-013542	Sun Nov 08, 2026 04:53 PM	spo2	94.0	nasal cannula
VIT-013543	Sun Nov 08, 2026 04:53 PM	rr	24.0
VIT-013544	Sun Nov 08, 2026 04:53 PM	o2_lpm	2.0	nasal cannula
VIT-013585	Sun Nov 08, 2026 04:53 PM	temp_c	37.0
VIT-013586	Sun Nov 08, 2026 04:53 PM	hr	71.0
VIT-013587	Sun Nov 08, 2026 04:53 PM	map	90.0
VIT-013588	Sun Nov 08, 2026 04:53 PM	gcs	15.0

Medications, orders, echo, history (4)

MED-000540 11-05 09:33 ceftriaxone per protocol IV
MED-000541 11-06 05:00 cefepime per protocol IV
MED-000542 11-07 05:00 ceftriaxone per protocol IV
ORD-000123 11-05 09:03 blood_culture: blood cultures x2

Notes

History and physical · DOC-000466 · Dr. Priya Thorne (resident) · Thu Nov 05, 2026 11:33 AM

Cited facts from this note (2)

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

Show source for infection_source

… 2026-11-05 08:33 Service: Hospital Medicine Attending: Dr. Kenji Stavros History of present illness: 68-year-old man admitted with sepsis. 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: increased work of bre …
work_of_breathing: increased · cited p. 1, line 8 · confidence 0.90

Show source for work_of_breathing

… lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: none significant. Review of systems otherwise negative. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. Sepsis: antibiotics, fluids. 2. Community-acquired pneumonia: antibiotics.

Source document DOC-000466: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Amara Greaves   MRN: MRN89238449   Admitted: 2026-11-05 08:33
Service: Hospital Medicine   Attending: Dr. Kenji Stavros

History of present illness: 68-year-old man admitted with sepsis. 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: increased work of breathing with accessory muscle use.
Assessment and plan:
1. Sepsis: antibiotics, fluids.
2. Community-acquired pneumonia: antibiotics.

Progress note · DOC-000467 · Dr. Priya Thorne (resident) · Sat Nov 07, 2026 10:33 AM

Source document DOC-000467: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Amara Greaves   MRN: MRN89238449   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.
2. AKI: trend creatinine, hold nephrotoxins, strict intake and output.
3. Hypoxemia: supplemental oxygen, wean as tolerated.

Resident: Dr. Priya Thorne   Attending cosign: completed

Discharge summary · DOC-000468 · Dr. Kenji Stavros (attending) · Sun Nov 08, 2026 04:58 PM

Source document DOC-000468: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Amara Greaves   MRN: MRN89238449
Admitted 2026-11-05; discharged 2026-11-08.

Discharge diagnoses:
- sepsis
- community-acquired pneumonia
- AKI
- hypoxemia

Disposition: home with follow-up.