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-00154: Pilar Jessup

61M · MRN39267302 · Hospital Medicine · admitted Mon Nov 09, 2026 07:17 PM · in hospital · attending Dr. Odette Galloway · resident Dr. Keira Upfield · 177 cm, 72.8 kg

Documented diagnoses (current)

Principal: “sepsis” · A41.9 Sepsis, unspecified organism
“urinary tract infection” · N39.0 Urinary tract infection, site not specified
“anemia” · D64.9 Anemia, unspecified
“hyperlipidemia” · E78.5 Hyperlipidemia, unspecified

Illustrative grouping now: MS-DRG 872 Septicemia or severe sepsis without MV >96 hours without MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 872.

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=1.054, t.ratio_s1=1.5, creat_rise_48h=0.04, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, t.uo_s1_h=6	false
derived: stage3	`meets_definition and (creat_ratio >= t.ratio_s3 or creat_peak >= t.scr_s3 or rrt_started or coalesce(uo_hours_lt_0_3 >= t.uo_s3_h, false) or coalesce(anuria_hours >= t.anuria_h, false))`	meets_definition=False, creat_ratio=1.054, t.ratio_s3=3.0, creat_peak=0.97, 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=1.054, t.ratio_s2=2.0, uo_hours_lt_0_5=unknown, t.uo_s2_h=12	false
derived: stage	`case(stage3, 3, stage2, 2, meets_definition, 1, 0)`	stage3=False, stage2=False, meets_definition=False	0
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=0.04, t.rise_abs=0.3, rrt_started=False	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	stage=0, baseline_independent=True	false
outcome: aki_presumed_baseline	`stage >= 1`	stage=0	false
outcome: not_met	`stage == 0`	stage=0	true

Acute blood loss anaemia

Criteria met

No gap

Supported as documented (D64.9).

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=10.36, 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=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=True, acute_fall=False	false
outcome: anaemia_only	`anaemic and hgb_drop < t.drop_min and prbc_units == 0`	anaemic=True, hgb_drop=0.3, t.drop_min=1.0, prbc_units=0	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=347, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=93.4, egfr_late=94.6	94.6
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=93.4, t.g2=60, egfr_late=94.6	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=94.6, 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=93.4, egfr_late=94.6, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=94.6, 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

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=61, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=23.2, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=23.2, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=23.2, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=23.2, 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=94.0, 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=94.0, t.spo2_ra=88, pao2_min_ra=unknown, t.pao2=60, pf_min=unknown, t.pf=300	false
derived: distress	`coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support`	rr_max=20.0, t.rr_distress=28, wob_increased=unknown, adv_resp_support=False	false
outcome: chronic_baseline	`home_o2 and hypoxemia`	home_o2=False, hypoxemia=False	false
outcome: met	`hypoxemia and distress`	hypoxemia=False, distress=False	false
outcome: hypoxemia_only	`hypoxemia`	hypoxemia=False	false
outcome: not_met	`measured and not hypoxemia and o2_max_lpm <= t.o2_low and not adv_resp_support`	measured=True, hypoxemia=False, o2_max_lpm=0.0, t.o2_low=2, adv_resp_support=False	true

Sepsis

Criteria 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=39.1, t.t_hi=38, temp_min_48h=38.5, t.t_lo=36	true
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=122.0, 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=20.0, t.rr=20, paco2_min_48h=unknown, t.paco2=32	false
derived: sirs_wbc	`coalesce(wbc_max_48h > t.wbc_hi, false) or coalesce(wbc_min_48h < t.wbc_lo, false) or coalesce(bands_max_48h > t.bands, false)`	wbc_max_48h=16.46, t.wbc_hi=12, wbc_min_48h=14.66, 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=False, sirs_wbc=True	3
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=84.0	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=0.51	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=64.0	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=0.96	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=0.92	0
derived: sofa_delta	`sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline`	sofa_resp=0, sofa_coag=2, sofa_liver=0, sofa_cardio=1, sofa_cns=0, sofa_renal=0, sofa_renal_baseline=0	3
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=3, t.sofa_delta=2	true
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=True, sirs_count=3, 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=2.9, 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 (29)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-005267	Wed Oct 08, 2025 09:15 AM	creatinine	0.93 mg/dL
LAB-005268	Sun Sep 20, 2026 10:05 AM	creatinine	0.92 mg/dL
LAB-005269	Mon Nov 09, 2026 08:17 PM	creatinine	0.96 mg/dL
LAB-005274	Mon Nov 09, 2026 08:17 PM	sodium	141.0 mmol/L
LAB-005279	Mon Nov 09, 2026 08:17 PM	hemoglobin	10.62 g/dL
LAB-005284	Mon Nov 09, 2026 08:17 PM	wbc	14.76 x10^3/uL
LAB-005285	Mon Nov 09, 2026 08:17 PM	platelets	87.0 x10^3/uL
LAB-005294	Mon Nov 09, 2026 08:17 PM	bilirubin	0.51 mg/dL
LAB-005295	Mon Nov 09, 2026 08:17 PM	lactate	2.9 mmol/L
LAB-005270	Tue Nov 10, 2026 05:00 AM	creatinine	0.93 mg/dL
LAB-005275	Tue Nov 10, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-005280	Tue Nov 10, 2026 05:00 AM	hemoglobin	10.67 g/dL
LAB-005286	Tue Nov 10, 2026 05:00 AM	wbc	14.66 x10^3/uL
LAB-005287	Tue Nov 10, 2026 05:00 AM	platelets	84.0 x10^3/uL
LAB-005271	Wed Nov 11, 2026 05:00 AM	creatinine	0.94 mg/dL
LAB-005276	Wed Nov 11, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-005281	Wed Nov 11, 2026 05:00 AM	hemoglobin	10.5 g/dL
LAB-005288	Wed Nov 11, 2026 05:00 AM	wbc	16.46 x10^3/uL
LAB-005289	Wed Nov 11, 2026 05:00 AM	platelets	86.0 x10^3/uL
LAB-005272	Thu Nov 12, 2026 05:00 AM	creatinine	0.97 mg/dL
LAB-005277	Thu Nov 12, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-005282	Thu Nov 12, 2026 05:00 AM	hemoglobin	10.36 g/dL
LAB-005290	Thu Nov 12, 2026 05:00 AM	wbc	9.06 x10^3/uL
LAB-005291	Thu Nov 12, 2026 05:00 AM	platelets	180.0 x10^3/uL
LAB-005273	Fri Nov 13, 2026 05:00 AM	creatinine	0.91 mg/dL
LAB-005278	Fri Nov 13, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-005283	Fri Nov 13, 2026 05:00 AM	hemoglobin	10.58 g/dL
LAB-005292	Fri Nov 13, 2026 05:00 AM	wbc	5.79 x10^3/uL
LAB-005293	Fri Nov 13, 2026 05:00 AM	platelets	284.0 x10^3/uL

Vitals (72)

Vitals
Row	When	Kind	Value	Detail
VIT-015143	Mon Nov 09, 2026 07:37 PM	spo2	95.0	room air
VIT-015144	Mon Nov 09, 2026 07:37 PM	rr	14.0
VIT-015167	Mon Nov 09, 2026 07:37 PM	temp_c	39.1
VIT-015168	Mon Nov 09, 2026 07:37 PM	hr	103.0
VIT-015169	Mon Nov 09, 2026 07:37 PM	map	68.0
VIT-015170	Mon Nov 09, 2026 07:37 PM	gcs	15.0
VIT-015145	Tue Nov 10, 2026 03:37 AM	spo2	98.0	room air
VIT-015146	Tue Nov 10, 2026 03:37 AM	rr	15.0
VIT-015171	Tue Nov 10, 2026 03:37 AM	temp_c	38.7
VIT-015172	Tue Nov 10, 2026 03:37 AM	hr	108.0
VIT-015173	Tue Nov 10, 2026 03:37 AM	map	67.0
VIT-015174	Tue Nov 10, 2026 03:37 AM	gcs	15.0
VIT-015147	Tue Nov 10, 2026 11:37 AM	spo2	96.0	room air
VIT-015148	Tue Nov 10, 2026 11:37 AM	rr	17.0
VIT-015175	Tue Nov 10, 2026 11:37 AM	temp_c	38.6
VIT-015176	Tue Nov 10, 2026 11:37 AM	hr	105.0
VIT-015177	Tue Nov 10, 2026 11:37 AM	map	68.0
VIT-015178	Tue Nov 10, 2026 11:37 AM	gcs	15.0
VIT-015149	Tue Nov 10, 2026 07:37 PM	spo2	99.0	room air
VIT-015150	Tue Nov 10, 2026 07:37 PM	rr	20.0
VIT-015179	Tue Nov 10, 2026 07:37 PM	temp_c	39.0
VIT-015180	Tue Nov 10, 2026 07:37 PM	hr	116.0
VIT-015181	Tue Nov 10, 2026 07:37 PM	map	67.0
VIT-015182	Tue Nov 10, 2026 07:37 PM	gcs	15.0
VIT-015151	Wed Nov 11, 2026 03:37 AM	spo2	99.0	room air
VIT-015152	Wed Nov 11, 2026 03:37 AM	rr	19.0
VIT-015183	Wed Nov 11, 2026 03:37 AM	temp_c	38.9
VIT-015184	Wed Nov 11, 2026 03:37 AM	hr	122.0
VIT-015185	Wed Nov 11, 2026 03:37 AM	map	65.0
VIT-015186	Wed Nov 11, 2026 03:37 AM	gcs	15.0
VIT-015153	Wed Nov 11, 2026 11:37 AM	spo2	95.0	room air
VIT-015154	Wed Nov 11, 2026 11:37 AM	rr	17.0
VIT-015187	Wed Nov 11, 2026 11:37 AM	temp_c	38.5
VIT-015188	Wed Nov 11, 2026 11:37 AM	hr	104.0
VIT-015189	Wed Nov 11, 2026 11:37 AM	map	64.0
VIT-015190	Wed Nov 11, 2026 11:37 AM	gcs	15.0
VIT-015155	Wed Nov 11, 2026 07:37 PM	spo2	94.0	room air
VIT-015156	Wed Nov 11, 2026 07:37 PM	rr	20.0
VIT-015191	Wed Nov 11, 2026 07:37 PM	temp_c	37.4
VIT-015192	Wed Nov 11, 2026 07:37 PM	hr	73.0
VIT-015193	Wed Nov 11, 2026 07:37 PM	map	91.0
VIT-015194	Wed Nov 11, 2026 07:37 PM	gcs	15.0
VIT-015157	Thu Nov 12, 2026 03:37 AM	spo2	98.0	room air
VIT-015158	Thu Nov 12, 2026 03:37 AM	rr	15.0
VIT-015195	Thu Nov 12, 2026 03:37 AM	temp_c	37.1
VIT-015196	Thu Nov 12, 2026 03:37 AM	hr	86.0
VIT-015197	Thu Nov 12, 2026 03:37 AM	map	92.0
VIT-015198	Thu Nov 12, 2026 03:37 AM	gcs	15.0
VIT-015159	Thu Nov 12, 2026 11:37 AM	spo2	95.0	room air
VIT-015160	Thu Nov 12, 2026 11:37 AM	rr	20.0
VIT-015199	Thu Nov 12, 2026 11:37 AM	temp_c	37.2
VIT-015200	Thu Nov 12, 2026 11:37 AM	hr	70.0
VIT-015201	Thu Nov 12, 2026 11:37 AM	map	90.0
VIT-015202	Thu Nov 12, 2026 11:37 AM	gcs	15.0
VIT-015161	Thu Nov 12, 2026 07:37 PM	spo2	96.0	room air
VIT-015162	Thu Nov 12, 2026 07:37 PM	rr	16.0
VIT-015203	Thu Nov 12, 2026 07:37 PM	temp_c	36.7
VIT-015204	Thu Nov 12, 2026 07:37 PM	hr	80.0
VIT-015205	Thu Nov 12, 2026 07:37 PM	map	79.0
VIT-015206	Thu Nov 12, 2026 07:37 PM	gcs	15.0
VIT-015163	Fri Nov 13, 2026 03:37 AM	spo2	96.0	room air
VIT-015164	Fri Nov 13, 2026 03:37 AM	rr	20.0
VIT-015207	Fri Nov 13, 2026 03:37 AM	temp_c	37.5
VIT-015208	Fri Nov 13, 2026 03:37 AM	hr	72.0
VIT-015209	Fri Nov 13, 2026 03:37 AM	map	78.0
VIT-015210	Fri Nov 13, 2026 03:37 AM	gcs	15.0
VIT-015165	Fri Nov 13, 2026 11:37 AM	spo2	96.0	room air
VIT-015166	Fri Nov 13, 2026 11:37 AM	rr	15.0
VIT-015211	Fri Nov 13, 2026 11:37 AM	temp_c	36.9
VIT-015212	Fri Nov 13, 2026 11:37 AM	hr	75.0
VIT-015213	Fri Nov 13, 2026 11:37 AM	map	75.0
VIT-015214	Fri Nov 13, 2026 11:37 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000617 11-09 20:17 ceftriaxone per protocol IV
MED-000618 11-10 05:00 piperacillin-tazobactam per protocol IV
MED-000619 11-11 05:00 cefepime per protocol IV
ORD-000133 11-09 19:47 blood_culture: blood cultures x2

Notes

History and physical · DOC-000521 · Dr. Keira Upfield (resident) · Mon Nov 09, 2026 10:17 PM

Cited facts from this note (1)

infection_source: acute pyelonephritis · cited p. 1, line 5 · confidence 0.85

Show source for infection_source

… vice: Hospital Medicine Attending: Dr. Odette Galloway History of present illness: 61-year-old man admitted with sepsis. Urinalysis with pyuria; treated for acute pyelonephritis with cefepime. Past medical history: hyperlipidemia. Review of systems otherwise negative. Exam: Lungs: clear to auscultation bilaterally. Assessment and plan: …

Source document DOC-000521: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Pilar Jessup   MRN: MRN39267302   Admitted: 2026-11-09 19:17
Service: Hospital Medicine   Attending: Dr. Odette Galloway

History of present illness: 61-year-old man admitted with sepsis. Urinalysis with pyuria; treated for acute pyelonephritis with cefepime.
Past medical history: hyperlipidemia.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Sepsis: antibiotics, fluids.
2. Urinary tract infection: antibiotics.

Progress note · DOC-000522 · Dr. Keira Upfield (resident) · Fri Nov 13, 2026 12:55 PM · awaiting cosign

Source document DOC-000522: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Pilar Jessup   MRN: MRN39267302   Hospital day 4

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.
2. Anemia: trend hemoglobin.

Resident: Dr. Keira Upfield   Attending cosign: pending