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-00159: Ximena Pemberton

66F · MRN25625425 · Pulmonology · admitted Sat Oct 31, 2026 10:30 AM · discharged Tue Nov 03, 2026 12:33 PM · attending Dr. Odette Galloway · 164 cm, 99.1 kg

Documented diagnoses (current)

Principal: “COPD exacerbation” · J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
“class 2 obesity” · E66.812 Obesity, class 2
“CKD stage 3a” · N18.31 Chronic kidney disease, stage 3a
“AKI” · N17.9 Acute kidney failure, unspecified
“congestive heart failure” · I50.9 Heart failure, unspecified
“acute hypoxic respiratory failure” · J96.01 Acute respiratory failure with hypoxia
“anemia” · D64.9 Anemia, unspecified

Illustrative grouping now: MS-DRG 190 Chronic obstructive pulmonary disease with MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 190.

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=1.82, t.ratio_s1=1.5, creat_rise_48h=0.36, 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=1.82, t.ratio_s3=3.0, creat_peak=1.62, 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=1.82, 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=0.36, 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 met

Specificity gap

Documented “anemia” (D64.9); criteria support the more specific Acute blood loss anemia (D62).

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=9.49, 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=3.5, t.drop_major=2.0, prbc_units=2, t.prbc_major=2	true
outcome: met	`bleeding_documented and anaemic and acute_fall`	bleeding_documented=True, anaemic=True, acute_fall=True	true

Chronic kidney disease

Clinical judgement required

Clinical judgement required: Pre-admission eGFR values fall on both sides of 60.

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=233, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=55.4, egfr_late=71.5	71.5
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=55.4, t.g2=60, egfr_late=71.5	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=71.5, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15	G1-G2
outcome: duration_not_shown	`not chronic`	chronic=True	false
outcome: straddles_60	`not both_below_60 and min(egfr_early, egfr_late) < t.g2`	both_below_60=False, egfr_early=55.4, egfr_late=71.5, t.g2=60	true

Heart failure

Criteria met

Specificity gap

Documented “congestive heart failure” (I50.9); criteria support the more specific Acute on chronic diastolic (HFpEF) heart failure (I50.33).

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=1293.0, t.bnp=100, ntprobnp_max=unknown, t.ntprobnp=300	true
derived: acute_count	`count(iv_loop_diuretic, np_elevated, new_o2)`	iv_loop_diuretic=True, np_elevated=True, new_o2=True	3
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=56.0, t.ref=40, t.pres=50	diastolic
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=56.0, 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=3, hf_history=True	acute on chronic
outcome: improved_ef	`improved`	improved=False	false
outcome: midrange	`hf_type == 'midrange'`	hf_type=diastolic	false
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	hf_type=diastolic, acuity=acute on chronic	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	hf_type=diastolic, acuity=acute on chronic	false
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	hf_type=diastolic, acuity=acute on chronic	false
outcome: dia_aoc	`hf_type == 'diastolic' and acuity == 'acute on chronic'`	hf_type=diastolic, acuity=acute on chronic	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=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 met

No gap

Supported as documented (E66.812).

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=66, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=36.8, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=36.8, t.c2=35	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

No gap

Supported as documented (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=85.0, 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=85.0, 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 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=88.0, 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=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=10.43, t.wbc_hi=12, wbc_min_48h=9.97, 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=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=193.0	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=0.58	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=74.0	0
derived: sofa_cns	`coalesce(case(gcs_min_48h < 6, 4, gcs_min_48h < 10, 3, gcs_min_48h < 13, 2, gcs_min_48h < 15, 1, 0), 0)`	gcs_min_48h=15.0	0
derived: sofa_renal	`coalesce(case(creat_max_48h >= 5, 4, creat_max_48h >= 3.5, 3, creat_max_48h >= 2, 2, creat_max_48h >= 1.2, 1, 0), 0)`	creat_max_48h=1.62	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=0.89	0
derived: sofa_delta	`sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline`	sofa_resp=2, sofa_coag=0, sofa_liver=0, sofa_cardio=0, sofa_cns=0, sofa_renal=1, sofa_renal_baseline=0	3
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=False, sofa_delta=3, t.sofa_delta=2	false
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=False, 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=False	true

Structured data

Labs (26)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-005421	Sat Jan 10, 2026 09:15 AM	creatinine	1.1 mg/dL
LAB-005422	Tue Sep 01, 2026 10:05 AM	creatinine	0.89 mg/dL
LAB-005428	Sat Oct 31, 2026 10:55 AM	pao2	52.0 mmHg
LAB-005429	Sat Oct 31, 2026 10:55 AM	fio2	21.0 %
LAB-005423	Sat Oct 31, 2026 11:30 AM	creatinine	1.26 mg/dL
LAB-005427	Sat Oct 31, 2026 11:30 AM	bnp	1293.0 pg/mL
LAB-005430	Sat Oct 31, 2026 11:30 AM	sodium	137.0 mmol/L
LAB-005434	Sat Oct 31, 2026 11:30 AM	hemoglobin	13.0 g/dL
LAB-005438	Sat Oct 31, 2026 11:30 AM	wbc	9.97 x10^3/uL
LAB-005439	Sat Oct 31, 2026 11:30 AM	platelets	296.0 x10^3/uL
LAB-005446	Sat Oct 31, 2026 11:30 AM	bilirubin	0.58 mg/dL
LAB-005424	Sun Nov 01, 2026 05:00 AM	creatinine	1.62 mg/dL
LAB-005431	Sun Nov 01, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-005435	Sun Nov 01, 2026 05:00 AM	hemoglobin	10.89 g/dL
LAB-005440	Sun Nov 01, 2026 05:00 AM	wbc	10.43 x10^3/uL
LAB-005441	Sun Nov 01, 2026 05:00 AM	platelets	246.0 x10^3/uL
LAB-005425	Mon Nov 02, 2026 05:00 AM	creatinine	1.46 mg/dL
LAB-005432	Mon Nov 02, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-005436	Mon Nov 02, 2026 05:00 AM	hemoglobin	9.49 g/dL
LAB-005442	Mon Nov 02, 2026 05:00 AM	wbc	10.03 x10^3/uL
LAB-005443	Mon Nov 02, 2026 05:00 AM	platelets	193.0 x10^3/uL
LAB-005426	Tue Nov 03, 2026 05:00 AM	creatinine	1.21 mg/dL
LAB-005433	Tue Nov 03, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-005437	Tue Nov 03, 2026 05:00 AM	hemoglobin	10.29 g/dL
LAB-005444	Tue Nov 03, 2026 05:00 AM	wbc	6.59 x10^3/uL
LAB-005445	Tue Nov 03, 2026 05:00 AM	platelets	269.0 x10^3/uL

Vitals (70)

Vitals
Row	When	Kind	Value	Detail
VIT-015580	Sat Oct 31, 2026 10:50 AM	spo2	85.0	room air
VIT-015581	Sat Oct 31, 2026 10:50 AM	rr	28.0
VIT-015610	Sat Oct 31, 2026 10:50 AM	temp_c	37.5
VIT-015611	Sat Oct 31, 2026 10:50 AM	hr	72.0
VIT-015612	Sat Oct 31, 2026 10:50 AM	map	80.0
VIT-015613	Sat Oct 31, 2026 10:50 AM	gcs	15.0
VIT-015582	Sat Oct 31, 2026 11:00 AM	o2_lpm	4.0	nasal cannula
VIT-015583	Sat Oct 31, 2026 06:50 PM	spo2	93.0	nasal cannula
VIT-015584	Sat Oct 31, 2026 06:50 PM	rr	22.0
VIT-015585	Sat Oct 31, 2026 06:50 PM	o2_lpm	3.0	nasal cannula
VIT-015614	Sat Oct 31, 2026 06:50 PM	temp_c	36.8
VIT-015615	Sat Oct 31, 2026 06:50 PM	hr	69.0
VIT-015616	Sat Oct 31, 2026 06:50 PM	map	74.0
VIT-015617	Sat Oct 31, 2026 06:50 PM	gcs	15.0
VIT-015586	Sun Nov 01, 2026 02:50 AM	spo2	94.0	nasal cannula
VIT-015587	Sun Nov 01, 2026 02:50 AM	rr	26.0
VIT-015588	Sun Nov 01, 2026 02:50 AM	o2_lpm	4.0	nasal cannula
VIT-015618	Sun Nov 01, 2026 02:50 AM	temp_c	36.7
VIT-015619	Sun Nov 01, 2026 02:50 AM	hr	86.0
VIT-015620	Sun Nov 01, 2026 02:50 AM	map	83.0
VIT-015621	Sun Nov 01, 2026 02:50 AM	gcs	15.0
VIT-015589	Sun Nov 01, 2026 10:50 AM	spo2	93.0	nasal cannula
VIT-015590	Sun Nov 01, 2026 10:50 AM	rr	23.0
VIT-015591	Sun Nov 01, 2026 10:50 AM	o2_lpm	3.0	nasal cannula
VIT-015622	Sun Nov 01, 2026 10:50 AM	temp_c	36.7
VIT-015623	Sun Nov 01, 2026 10:50 AM	hr	88.0
VIT-015624	Sun Nov 01, 2026 10:50 AM	map	81.0
VIT-015625	Sun Nov 01, 2026 10:50 AM	gcs	15.0
VIT-015592	Sun Nov 01, 2026 06:50 PM	spo2	94.0	nasal cannula
VIT-015593	Sun Nov 01, 2026 06:50 PM	rr	21.0
VIT-015594	Sun Nov 01, 2026 06:50 PM	o2_lpm	2.0	nasal cannula
VIT-015626	Sun Nov 01, 2026 06:50 PM	temp_c	37.0
VIT-015627	Sun Nov 01, 2026 06:50 PM	hr	74.0
VIT-015628	Sun Nov 01, 2026 06:50 PM	map	87.0
VIT-015629	Sun Nov 01, 2026 06:50 PM	gcs	15.0
VIT-015595	Mon Nov 02, 2026 02:50 AM	spo2	92.0	nasal cannula
VIT-015596	Mon Nov 02, 2026 02:50 AM	rr	20.0
VIT-015597	Mon Nov 02, 2026 02:50 AM	o2_lpm	2.0	nasal cannula
VIT-015630	Mon Nov 02, 2026 02:50 AM	temp_c	37.0
VIT-015631	Mon Nov 02, 2026 02:50 AM	hr	75.0
VIT-015632	Mon Nov 02, 2026 02:50 AM	map	89.0
VIT-015633	Mon Nov 02, 2026 02:50 AM	gcs	15.0
VIT-015598	Mon Nov 02, 2026 10:50 AM	spo2	94.0	nasal cannula
VIT-015599	Mon Nov 02, 2026 10:50 AM	rr	20.0
VIT-015600	Mon Nov 02, 2026 10:50 AM	o2_lpm	4.0	nasal cannula
VIT-015634	Mon Nov 02, 2026 10:50 AM	temp_c	37.6
VIT-015635	Mon Nov 02, 2026 10:50 AM	hr	91.0
VIT-015636	Mon Nov 02, 2026 10:50 AM	map	79.0
VIT-015637	Mon Nov 02, 2026 10:50 AM	gcs	15.0
VIT-015601	Mon Nov 02, 2026 06:50 PM	spo2	92.0	nasal cannula
VIT-015602	Mon Nov 02, 2026 06:50 PM	rr	24.0
VIT-015603	Mon Nov 02, 2026 06:50 PM	o2_lpm	2.0	nasal cannula
VIT-015638	Mon Nov 02, 2026 06:50 PM	temp_c	37.5
VIT-015639	Mon Nov 02, 2026 06:50 PM	hr	74.0
VIT-015640	Mon Nov 02, 2026 06:50 PM	map	81.0
VIT-015641	Mon Nov 02, 2026 06:50 PM	gcs	15.0
VIT-015604	Tue Nov 03, 2026 02:50 AM	spo2	95.0	nasal cannula
VIT-015605	Tue Nov 03, 2026 02:50 AM	rr	23.0
VIT-015606	Tue Nov 03, 2026 02:50 AM	o2_lpm	4.0	nasal cannula
VIT-015642	Tue Nov 03, 2026 02:50 AM	temp_c	36.9
VIT-015643	Tue Nov 03, 2026 02:50 AM	hr	75.0
VIT-015644	Tue Nov 03, 2026 02:50 AM	map	90.0
VIT-015645	Tue Nov 03, 2026 02:50 AM	gcs	15.0
VIT-015607	Tue Nov 03, 2026 10:50 AM	spo2	94.0	nasal cannula
VIT-015608	Tue Nov 03, 2026 10:50 AM	rr	22.0
VIT-015609	Tue Nov 03, 2026 10:50 AM	o2_lpm	2.0	nasal cannula
VIT-015646	Tue Nov 03, 2026 10:50 AM	temp_c	37.1
VIT-015647	Tue Nov 03, 2026 10:50 AM	hr	90.0
VIT-015648	Tue Nov 03, 2026 10:50 AM	map	75.0
VIT-015649	Tue Nov 03, 2026 10:50 AM	gcs	15.0

Medications, orders, echo, history (9)

MED-000641 10-31 08:00 furosemide 40 mg IV
MED-000642 10-31 20:00 furosemide 40 mg IV
MED-000643 11-01 08:00 furosemide 40 mg IV
MED-000644 11-01 20:00 furosemide 40 mg IV
MED-000645 11-02 08:00 furosemide 40 mg IV
MED-000646 11-02 20:00 furosemide 40 mg IV
ORD-000138 11-01 09:00 transfusion_prbc: transfuse PRBC
ECH-000075 2026-11-01 echo LVEF 56.0%
HX-000058 history: heart failure with preserved ejection fraction

Notes

History and physical · DOC-000534 · Dr. Odette Galloway (attending) · Sat Oct 31, 2026 01:30 PM

Cited facts from this note (2)

bleeding_source: black tarry stools · cited p. 1, line 5 · confidence 0.85

Show source for bleeding_source

… ce: Pulmonology Attending: Dr. Odette Galloway History of present illness: 66-year-old woman admitted with COPD exacerbation. Hospital course complicated by black tarry stools. Past medical history: heart failure with preserved ejection fraction. Review of systems otherwise negative. Exam: Lungs: increased work of breathing with acce …
work_of_breathing: increased · cited p. 1, line 8 · confidence 0.90

Show source for work_of_breathing

… rse complicated by black tarry stools. Past medical history: heart failure with preserved ejection fraction. Review of systems otherwise negative. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. COPD exacerbation: bronchodilators and steroids. 2. CKD stage 3a: renally dose medications.

Source document DOC-000534: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Ximena Pemberton   MRN: MRN25625425   Admitted: 2026-10-31 10:30
Service: Pulmonology   Attending: Dr. Odette Galloway

History of present illness: 66-year-old woman admitted with COPD exacerbation. Hospital course complicated by black tarry stools.
Past medical history: heart failure with preserved ejection fraction.
Review of systems otherwise negative.
Exam: Lungs: increased work of breathing with accessory muscle use.
Assessment and plan:
1. COPD exacerbation: bronchodilators and steroids.
2. CKD stage 3a: renally dose medications.

Progress note · DOC-000535 · Dr. Odette Galloway (attending) · Mon Nov 02, 2026 01:30 PM

Source document DOC-000535: Progress note (synthetic)

PROGRESS NOTE (Attending)
Patient: Ximena Pemberton   MRN: MRN25625425   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. COPD exacerbation: continue current management.
2. Class 2 obesity: counsel on weight.
3. AKI: trend creatinine, hold nephrotoxins, strict intake and output.
4. Congestive heart failure: diuresis and daily weights; monitor electrolytes.
5. Acute hypoxic respiratory failure: supplemental oxygen, wean as tolerated.
6. Anemia: trend hemoglobin.

Attending: Dr. Odette Galloway

Discharge summary · DOC-000536 · Dr. Odette Galloway (attending) · Tue Nov 03, 2026 12:33 PM

Source document DOC-000536: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Ximena Pemberton   MRN: MRN25625425
Admitted 2026-10-31; discharged 2026-11-03.

Discharge diagnoses:
- COPD exacerbation
- class 2 obesity
- CKD stage 3a
- AKI
- congestive heart failure
- acute hypoxic respiratory failure
- anemia

Disposition: home with follow-up.