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-00156: Zara Penhallow

71F · MRN99329110 · Hospital Medicine · admitted Wed Nov 11, 2026 07:38 PM · in hospital · attending Dr. Gideon Zeller · 155 cm, 66.7 kg

Documented diagnoses (current)

Principal: “urinary tract infection” · N39.0 Urinary tract infection, site not specified
“hypoxia” · R09.02 Hypoxemia
“GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis
“hypertension” · I10 Essential (primary) hypertension
“hyperlipidemia” · E78.5 Hyperlipidemia, unspecified

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 689.

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=0.02, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, t.uo_s1_h=6	false
derived: stage3	`meets_definition and (creat_ratio >= t.ratio_s3 or creat_peak >= t.scr_s3 or rrt_started or coalesce(uo_hours_lt_0_3 >= t.uo_s3_h, false) or coalesce(anuria_hours >= t.anuria_h, false))`	meets_definition=False, creat_ratio=1.054, 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=0.02, t.rise_abs=0.3, rrt_started=False	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	stage=0, baseline_independent=True	false
outcome: aki_presumed_baseline	`stage >= 1`	stage=0	false
outcome: not_met	`stage == 0`	stage=0	true

Acute blood loss anaemia

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule blood_loss_anemia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: anaemic	`case(sex == 'M', hgb_nadir < t.hb_m, sex == 'F', hgb_nadir < t.hb_f, null)`	sex=F, hgb_nadir=13.81, 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=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=0.3, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=13.81, 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=286, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=69.3, egfr_late=66.6	69.3
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=69.3, t.g2=60, egfr_late=66.6	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=69.3, 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=69.3, egfr_late=66.6, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=69.3, 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=71, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=27.8, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=27.8, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=27.8, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=27.8, 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 “hypoxia” (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=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=84.0, t.spo2_ra=88, pao2_min_ra=unknown, t.pao2=60, pf_min=unknown, t.pf=300	true
derived: distress	`coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support`	rr_max=30.0, t.rr_distress=28, wob_increased=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 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=37.5, t.t_hi=38, temp_min_48h=36.7, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=89.0, t.hr=90	false
derived: sirs_rr	`coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false)`	rr_max_48h=30.0, t.rr=20, paco2_min_48h=unknown, t.paco2=32	true
derived: sirs_wbc	`coalesce(wbc_max_48h > t.wbc_hi, false) or coalesce(wbc_min_48h < t.wbc_lo, false) or coalesce(bands_max_48h > t.bands, false)`	wbc_max_48h=10.36, t.wbc_hi=12, wbc_min_48h=6.21, t.wbc_lo=4, bands_max_48h=unknown, t.bands=10	false
derived: sirs_count	`count(sirs_temp, sirs_hr, sirs_rr, sirs_wbc)`	sirs_temp=False, sirs_hr=False, sirs_rr=True, sirs_wbc=False	1
derived: sofa_resp	`coalesce(case(pf_min_48h < 100 and adv_resp_support, 4, pf_min_48h < 200 and adv_resp_support, 3, pf_min_48h < 300, 2, pf_min_48h < 400, 1, 0), 0)`	pf_min_48h=unknown, adv_resp_support=False	0
derived: sofa_coag	`coalesce(case(platelets_min_48h < 20, 4, platelets_min_48h < 50, 3, platelets_min_48h < 100, 2, platelets_min_48h < 150, 1, 0), 0)`	platelets_min_48h=247.0	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=0.79	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=81.0	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=0.97	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=0, sofa_liver=0, sofa_cardio=0, sofa_cns=0, sofa_renal=0, sofa_renal_baseline=0	0
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=0, t.sofa_delta=2	false
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=True, sirs_count=1, t.sirs_min=2	false
derived: shock	`sepsis3 and norepi_max_48h > 0 and coalesce(lactate_max_48h > t.lactate, false)`	sepsis3=False, norepi_max_48h=0.0, lactate_max_48h=unknown, t.lactate=2	false
outcome: no_infection	`not infection_documented`	infection_documented=True	false
outcome: septic_shock	`shock`	shock=False	false
outcome: both	`sepsis3 and sepsis2`	sepsis3=False, sepsis2=False	false
outcome: sepsis3_only	`sepsis3`	sepsis3=False	false
outcome: definitions_disagree	`sepsis2`	sepsis2=False	false
outcome: neither	`true`	—	true

Structured data

Labs (18)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-005325	Fri Oct 31, 2025 09:15 AM	creatinine	0.89 mg/dL
LAB-005326	Thu Aug 13, 2026 10:05 AM	creatinine	0.92 mg/dL
LAB-005327	Wed Nov 11, 2026 08:38 PM	creatinine	0.95 mg/dL
LAB-005330	Wed Nov 11, 2026 08:38 PM	sodium	136.0 mmol/L
LAB-005333	Wed Nov 11, 2026 08:38 PM	hemoglobin	14.14 g/dL
LAB-005336	Wed Nov 11, 2026 08:38 PM	wbc	6.21 x10^3/uL
LAB-005337	Wed Nov 11, 2026 08:38 PM	platelets	307.0 x10^3/uL
LAB-005342	Wed Nov 11, 2026 08:38 PM	bilirubin	0.79 mg/dL
LAB-005328	Thu Nov 12, 2026 05:00 AM	creatinine	0.96 mg/dL
LAB-005331	Thu Nov 12, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-005334	Thu Nov 12, 2026 05:00 AM	hemoglobin	13.81 g/dL
LAB-005338	Thu Nov 12, 2026 05:00 AM	wbc	7.08 x10^3/uL
LAB-005339	Thu Nov 12, 2026 05:00 AM	platelets	250.0 x10^3/uL
LAB-005329	Fri Nov 13, 2026 05:00 AM	creatinine	0.97 mg/dL
LAB-005332	Fri Nov 13, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-005335	Fri Nov 13, 2026 05:00 AM	hemoglobin	13.9 g/dL
LAB-005340	Fri Nov 13, 2026 05:00 AM	wbc	10.36 x10^3/uL
LAB-005341	Fri Nov 13, 2026 05:00 AM	platelets	247.0 x10^3/uL

Vitals (42)

Vitals
Row	When	Kind	Value	Detail
VIT-015287	Wed Nov 11, 2026 07:58 PM	spo2	84.0	room air
VIT-015288	Wed Nov 11, 2026 07:58 PM	rr	30.0
VIT-015305	Wed Nov 11, 2026 07:58 PM	temp_c	37.3
VIT-015306	Wed Nov 11, 2026 07:58 PM	hr	84.0
VIT-015307	Wed Nov 11, 2026 07:58 PM	map	88.0
VIT-015308	Wed Nov 11, 2026 07:58 PM	gcs	15.0
VIT-015289	Wed Nov 11, 2026 08:08 PM	o2_lpm	4.0	nasal cannula
VIT-015290	Thu Nov 12, 2026 03:58 AM	spo2	93.0	nasal cannula
VIT-015291	Thu Nov 12, 2026 03:58 AM	rr	20.0
VIT-015292	Thu Nov 12, 2026 03:58 AM	o2_lpm	3.0	nasal cannula
VIT-015309	Thu Nov 12, 2026 03:58 AM	temp_c	37.5
VIT-015310	Thu Nov 12, 2026 03:58 AM	hr	89.0
VIT-015311	Thu Nov 12, 2026 03:58 AM	map	91.0
VIT-015312	Thu Nov 12, 2026 03:58 AM	gcs	15.0
VIT-015293	Thu Nov 12, 2026 11:58 AM	spo2	95.0	nasal cannula
VIT-015294	Thu Nov 12, 2026 11:58 AM	rr	25.0
VIT-015295	Thu Nov 12, 2026 11:58 AM	o2_lpm	4.0	nasal cannula
VIT-015313	Thu Nov 12, 2026 11:58 AM	temp_c	37.4
VIT-015314	Thu Nov 12, 2026 11:58 AM	hr	79.0
VIT-015315	Thu Nov 12, 2026 11:58 AM	map	81.0
VIT-015316	Thu Nov 12, 2026 11:58 AM	gcs	15.0
VIT-015296	Thu Nov 12, 2026 07:58 PM	spo2	94.0	nasal cannula
VIT-015297	Thu Nov 12, 2026 07:58 PM	rr	21.0
VIT-015298	Thu Nov 12, 2026 07:58 PM	o2_lpm	4.0	nasal cannula
VIT-015317	Thu Nov 12, 2026 07:58 PM	temp_c	36.7
VIT-015318	Thu Nov 12, 2026 07:58 PM	hr	76.0
VIT-015319	Thu Nov 12, 2026 07:58 PM	map	87.0
VIT-015320	Thu Nov 12, 2026 07:58 PM	gcs	15.0
VIT-015299	Fri Nov 13, 2026 03:58 AM	spo2	91.0	nasal cannula
VIT-015300	Fri Nov 13, 2026 03:58 AM	rr	21.0
VIT-015301	Fri Nov 13, 2026 03:58 AM	o2_lpm	4.0	nasal cannula
VIT-015321	Fri Nov 13, 2026 03:58 AM	temp_c	37.1
VIT-015322	Fri Nov 13, 2026 03:58 AM	hr	85.0
VIT-015323	Fri Nov 13, 2026 03:58 AM	map	81.0
VIT-015324	Fri Nov 13, 2026 03:58 AM	gcs	15.0
VIT-015302	Fri Nov 13, 2026 11:58 AM	spo2	92.0	nasal cannula
VIT-015303	Fri Nov 13, 2026 11:58 AM	rr	22.0
VIT-015304	Fri Nov 13, 2026 11:58 AM	o2_lpm	3.0	nasal cannula
VIT-015325	Fri Nov 13, 2026 11:58 AM	temp_c	36.8
VIT-015326	Fri Nov 13, 2026 11:58 AM	hr	70.0
VIT-015327	Fri Nov 13, 2026 11:58 AM	map	90.0
VIT-015328	Fri Nov 13, 2026 11:58 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000623 11-11 20:38 ceftriaxone per protocol IV
MED-000624 11-12 05:00 ceftriaxone per protocol IV
MED-000625 11-13 05:00 piperacillin-tazobactam per protocol IV
ORD-000135 11-11 20:08 blood_culture: blood cultures x2

Notes

History and physical · DOC-000525 · Dr. Gideon Zeller (attending) · Wed Nov 11, 2026 10:38 PM

Cited facts from this note (3)

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

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… ry tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime. Past medical history: GERD, hypertension, hyperlipidemia. Denies bleeding, chest pain or fever. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. Urinary tract infection: antibiotics.
infection_source: urinary tract infection · cited p. 1, line 5 · confidence 0.85

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… MRN99329110 Admitted: 2026-11-11 19:38 Service: Hospital Medicine Attending: Dr. Gideon Zeller History of present illness: 71-year-old woman admitted with urinary tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime. Past medical history: GERD, hypertension, hyperlipidemia. Denies bleeding, chest pa …
work_of_breathing: increased · cited p. 1, line 8 · confidence 0.90

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… treated for urinary tract infection with cefepime. Past medical history: GERD, hypertension, hyperlipidemia. Denies bleeding, chest pain or fever. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. Urinary tract infection: antibiotics.

Source document DOC-000525: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Zara Penhallow   MRN: MRN99329110   Admitted: 2026-11-11 19:38
Service: Hospital Medicine   Attending: Dr. Gideon Zeller

History of present illness: 71-year-old woman admitted with urinary tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime.
Past medical history: GERD, hypertension, hyperlipidemia.
Denies bleeding, chest pain or fever.
Exam: Lungs: increased work of breathing with accessory muscle use.
Assessment and plan:
1. Urinary tract infection: antibiotics.

Progress note · DOC-000526 · Dr. Gideon Zeller (attending) · Fri Nov 13, 2026 10:55 AM

Source document DOC-000526: Progress note (synthetic)

PROGRESS NOTE (Attending)
Patient: Zara Penhallow   MRN: MRN99329110   Hospital day 2

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Urinary tract infection: continue current management.
2. Hypoxia: supplemental oxygen, wean as tolerated.

Attending: Dr. Gideon Zeller