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-00155: Dmitri Rourke

73M · MRN86225198 · Hospital Medicine · admitted Mon Nov 09, 2026 05:43 PM · in hospital · attending Dr. Gideon Zeller · resident Dr. Greta Kowalczyk · 173 cm, 80.5 kg

Documented diagnoses (current)

Principal: “sepsis” · A41.9 Sepsis, unspecified organism
“community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism

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 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=1.044, 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=1.044, t.ratio_s3=3.0, creat_peak=1.19, 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=1.044, 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 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=13.2, 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=0.2, t.drop_major=2.0, prbc_units=0, t.prbc_major=2	false
outcome: met	`bleeding_documented and anaemic and acute_fall`	bleeding_documented=True, anaemic=False, acute_fall=False	false
outcome: anaemia_only	`anaemic and hgb_drop < t.drop_min and prbc_units == 0`	anaemic=False, hgb_drop=0.2, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=13.2, 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=290, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=68.6, egfr_late=67.9	68.6
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=68.6, t.g2=60, egfr_late=67.9	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=68.6, 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=68.6, egfr_late=67.9, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=68.6, 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=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=73, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=26.9, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=26.9, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=26.9, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=26.9, 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 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=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 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=39.3, t.t_hi=38, temp_min_48h=38.6, t.t_lo=36	true
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=115.0, 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=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=17.19, t.wbc_hi=12, wbc_min_48h=15.24, 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=83.0	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=0.88	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=1.19	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=1.14	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=2.82, 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-005296	Thu Dec 04, 2025 09:15 AM	creatinine	1.13 mg/dL
LAB-005297	Mon Sep 21, 2026 10:05 AM	creatinine	1.14 mg/dL
LAB-005298	Mon Nov 09, 2026 06:43 PM	creatinine	1.19 mg/dL
LAB-005303	Mon Nov 09, 2026 06:43 PM	sodium	141.0 mmol/L
LAB-005308	Mon Nov 09, 2026 06:43 PM	hemoglobin	13.44 g/dL
LAB-005313	Mon Nov 09, 2026 06:43 PM	wbc	15.24 x10^3/uL
LAB-005314	Mon Nov 09, 2026 06:43 PM	platelets	84.0 x10^3/uL
LAB-005323	Mon Nov 09, 2026 06:43 PM	bilirubin	0.88 mg/dL
LAB-005324	Mon Nov 09, 2026 06:43 PM	lactate	2.82 mmol/L
LAB-005299	Tue Nov 10, 2026 05:00 AM	creatinine	1.16 mg/dL
LAB-005304	Tue Nov 10, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-005309	Tue Nov 10, 2026 05:00 AM	hemoglobin	13.2 g/dL
LAB-005315	Tue Nov 10, 2026 05:00 AM	wbc	17.19 x10^3/uL
LAB-005316	Tue Nov 10, 2026 05:00 AM	platelets	93.0 x10^3/uL
LAB-005300	Wed Nov 11, 2026 05:00 AM	creatinine	1.15 mg/dL
LAB-005305	Wed Nov 11, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-005310	Wed Nov 11, 2026 05:00 AM	hemoglobin	13.7 g/dL
LAB-005317	Wed Nov 11, 2026 05:00 AM	wbc	16.2 x10^3/uL
LAB-005318	Wed Nov 11, 2026 05:00 AM	platelets	83.0 x10^3/uL
LAB-005301	Thu Nov 12, 2026 05:00 AM	creatinine	1.19 mg/dL
LAB-005306	Thu Nov 12, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-005311	Thu Nov 12, 2026 05:00 AM	hemoglobin	13.51 g/dL
LAB-005319	Thu Nov 12, 2026 05:00 AM	wbc	8.81 x10^3/uL
LAB-005320	Thu Nov 12, 2026 05:00 AM	platelets	177.0 x10^3/uL
LAB-005302	Fri Nov 13, 2026 05:00 AM	creatinine	1.16 mg/dL
LAB-005307	Fri Nov 13, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-005312	Fri Nov 13, 2026 05:00 AM	hemoglobin	13.34 g/dL
LAB-005321	Fri Nov 13, 2026 05:00 AM	wbc	7.29 x10^3/uL
LAB-005322	Fri Nov 13, 2026 05:00 AM	platelets	291.0 x10^3/uL

Vitals (72)

Vitals
Row	When	Kind	Value	Detail
VIT-015215	Mon Nov 09, 2026 06:03 PM	spo2	95.0	room air
VIT-015216	Mon Nov 09, 2026 06:03 PM	rr	17.0
VIT-015239	Mon Nov 09, 2026 06:03 PM	temp_c	39.1
VIT-015240	Mon Nov 09, 2026 06:03 PM	hr	115.0
VIT-015241	Mon Nov 09, 2026 06:03 PM	map	68.0
VIT-015242	Mon Nov 09, 2026 06:03 PM	gcs	15.0
VIT-015217	Tue Nov 10, 2026 02:03 AM	spo2	95.0	room air
VIT-015218	Tue Nov 10, 2026 02:03 AM	rr	18.0
VIT-015243	Tue Nov 10, 2026 02:03 AM	temp_c	39.3
VIT-015244	Tue Nov 10, 2026 02:03 AM	hr	110.0
VIT-015245	Tue Nov 10, 2026 02:03 AM	map	67.0
VIT-015246	Tue Nov 10, 2026 02:03 AM	gcs	15.0
VIT-015219	Tue Nov 10, 2026 10:03 AM	spo2	99.0	room air
VIT-015220	Tue Nov 10, 2026 10:03 AM	rr	15.0
VIT-015247	Tue Nov 10, 2026 10:03 AM	temp_c	38.6
VIT-015248	Tue Nov 10, 2026 10:03 AM	hr	107.0
VIT-015249	Tue Nov 10, 2026 10:03 AM	map	65.0
VIT-015250	Tue Nov 10, 2026 10:03 AM	gcs	15.0
VIT-015221	Tue Nov 10, 2026 06:03 PM	spo2	98.0	room air
VIT-015222	Tue Nov 10, 2026 06:03 PM	rr	19.0
VIT-015251	Tue Nov 10, 2026 06:03 PM	temp_c	38.8
VIT-015252	Tue Nov 10, 2026 06:03 PM	hr	106.0
VIT-015253	Tue Nov 10, 2026 06:03 PM	map	68.0
VIT-015254	Tue Nov 10, 2026 06:03 PM	gcs	15.0
VIT-015223	Wed Nov 11, 2026 02:03 AM	spo2	97.0	room air
VIT-015224	Wed Nov 11, 2026 02:03 AM	rr	15.0
VIT-015255	Wed Nov 11, 2026 02:03 AM	temp_c	38.6
VIT-015256	Wed Nov 11, 2026 02:03 AM	hr	107.0
VIT-015257	Wed Nov 11, 2026 02:03 AM	map	64.0
VIT-015258	Wed Nov 11, 2026 02:03 AM	gcs	15.0
VIT-015225	Wed Nov 11, 2026 10:03 AM	spo2	98.0	room air
VIT-015226	Wed Nov 11, 2026 10:03 AM	rr	19.0
VIT-015259	Wed Nov 11, 2026 10:03 AM	temp_c	38.7
VIT-015260	Wed Nov 11, 2026 10:03 AM	hr	105.0
VIT-015261	Wed Nov 11, 2026 10:03 AM	map	65.0
VIT-015262	Wed Nov 11, 2026 10:03 AM	gcs	15.0
VIT-015227	Wed Nov 11, 2026 06:03 PM	spo2	96.0	room air
VIT-015228	Wed Nov 11, 2026 06:03 PM	rr	16.0
VIT-015263	Wed Nov 11, 2026 06:03 PM	temp_c	37.4
VIT-015264	Wed Nov 11, 2026 06:03 PM	hr	73.0
VIT-015265	Wed Nov 11, 2026 06:03 PM	map	76.0
VIT-015266	Wed Nov 11, 2026 06:03 PM	gcs	15.0
VIT-015229	Thu Nov 12, 2026 02:03 AM	spo2	99.0	room air
VIT-015230	Thu Nov 12, 2026 02:03 AM	rr	17.0
VIT-015267	Thu Nov 12, 2026 02:03 AM	temp_c	37.3
VIT-015268	Thu Nov 12, 2026 02:03 AM	hr	90.0
VIT-015269	Thu Nov 12, 2026 02:03 AM	map	82.0
VIT-015270	Thu Nov 12, 2026 02:03 AM	gcs	15.0
VIT-015231	Thu Nov 12, 2026 10:03 AM	spo2	94.0	room air
VIT-015232	Thu Nov 12, 2026 10:03 AM	rr	19.0
VIT-015271	Thu Nov 12, 2026 10:03 AM	temp_c	37.3
VIT-015272	Thu Nov 12, 2026 10:03 AM	hr	71.0
VIT-015273	Thu Nov 12, 2026 10:03 AM	map	86.0
VIT-015274	Thu Nov 12, 2026 10:03 AM	gcs	15.0
VIT-015233	Thu Nov 12, 2026 06:03 PM	spo2	96.0	room air
VIT-015234	Thu Nov 12, 2026 06:03 PM	rr	18.0
VIT-015275	Thu Nov 12, 2026 06:03 PM	temp_c	36.6
VIT-015276	Thu Nov 12, 2026 06:03 PM	hr	72.0
VIT-015277	Thu Nov 12, 2026 06:03 PM	map	78.0
VIT-015278	Thu Nov 12, 2026 06:03 PM	gcs	15.0
VIT-015235	Fri Nov 13, 2026 02:03 AM	spo2	97.0	room air
VIT-015236	Fri Nov 13, 2026 02:03 AM	rr	17.0
VIT-015279	Fri Nov 13, 2026 02:03 AM	temp_c	36.6
VIT-015280	Fri Nov 13, 2026 02:03 AM	hr	77.0
VIT-015281	Fri Nov 13, 2026 02:03 AM	map	75.0
VIT-015282	Fri Nov 13, 2026 02:03 AM	gcs	15.0
VIT-015237	Fri Nov 13, 2026 10:03 AM	spo2	95.0	room air
VIT-015238	Fri Nov 13, 2026 10:03 AM	rr	16.0
VIT-015283	Fri Nov 13, 2026 10:03 AM	temp_c	37.5
VIT-015284	Fri Nov 13, 2026 10:03 AM	hr	68.0
VIT-015285	Fri Nov 13, 2026 10:03 AM	map	90.0
VIT-015286	Fri Nov 13, 2026 10:03 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000620 11-09 18:43 cefepime per protocol IV
MED-000621 11-10 05:00 cefepime per protocol IV
MED-000622 11-11 05:00 piperacillin-tazobactam per protocol IV
ORD-000134 11-09 18:13 blood_culture: blood cultures x2

Notes

History and physical · DOC-000523 · Dr. Greta Kowalczyk (resident) · Mon Nov 09, 2026 08:43 PM

Cited facts from this note (2)

bleeding_source: bleeding · cited p. 1, line 7 · confidence 0.50

Show source for bleeding_source

… man admitted with sepsis. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: none significant. Denies bleeding, chest pain or fever. Exam: Lungs: clear to auscultation bilaterally. Assessment and plan: 1. Sepsis: antibiotics, fluids. 2. Community-acquired pneumonia: ant …
infection_source: multifocal pneumonia · cited p. 1, line 5 · confidence 0.85

Show source for infection_source

… 2026-11-09 17:43 Service: Hospital Medicine Attending: Dr. Gideon Zeller History of present illness: 73-year-old man admitted with sepsis. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: none significant. Denies bleeding, chest pain or fever. Exam: Lungs: clear to auscultation …

Source document DOC-000523: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Dmitri Rourke   MRN: MRN86225198   Admitted: 2026-11-09 17:43
Service: Hospital Medicine   Attending: Dr. Gideon Zeller

History of present illness: 73-year-old man admitted with sepsis. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: none significant.
Denies bleeding, chest pain or fever.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Sepsis: antibiotics, fluids.
2. Community-acquired pneumonia: antibiotics.

Progress note · DOC-000524 · Dr. Greta Kowalczyk (resident) · Fri Nov 13, 2026 02:55 PM · awaiting cosign

Source document DOC-000524: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Dmitri Rourke   MRN: MRN86225198   Hospital day 4

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

Resident: Dr. Greta Kowalczyk   Attending cosign: pending