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-00009: Marisol Okafor

76M · MRN84006615 · Hospital Medicine · admitted Tue Nov 10, 2026 05:45 PM · in hospital · attending Dr. Kenji Stavros · resident Dr. Noor Halvorsen · 180 cm, 75.7 kg

Documented diagnoses (current)

Principal: “upper GI bleed” · K92.2 Gastrointestinal hemorrhage, unspecified
“malnourished” · E46 Unspecified protein-calorie malnutrition
“anemia” · D64.9 Anemia, unspecified
“hyperlipidemia” · E78.5 Hyperlipidemia, unspecified

Illustrative grouping now: MS-DRG 378 GI hemorrhage with CC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 378.

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=1.038, t.ratio_s1=1.5, creat_rise_48h=0.05, 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=1.038, t.ratio_s3=3.0, creat_peak=1.08, 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=1.038, 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=0.05, 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

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=M, hgb_nadir=10.23, 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=3.1, 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

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=278, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=74.4, egfr_late=74.4	74.4
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=74.4, t.g2=60, egfr_late=74.4	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=74.4, 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=74.4, egfr_late=74.4, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=74.4, 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=140.0, 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=140.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=140.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=140.0, t.low=135	true

Malnutrition

Criteria met

Specificity gap

Documented “malnourished” (E46); criteria support the more specific Moderate (non-severe) protein-calorie malnutrition (chronic illness context) (E44.0).

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=80.0, t.a_sev_intake_pct=50, intake_days=49.0, t.a_sev_intake_days=5	false
derived: a_mod_intake	`intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days`	intake_pct=80.0, t.a_mod_intake_pct=75, intake_days=49.0, t.a_mod_intake_days=7	false
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=90.0, wt_loss_pct=7.5	false
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=90.0, wt_loss_pct=7.5	true
derived: c_sev_intake	`intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=80.0, t.c_intake_pct=75, intake_days=49.0, t.c_intake_days=30	false
derived: c_mod_intake	`intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=80.0, t.c_intake_pct=75, intake_days=49.0, t.c_intake_days=30	false
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=90.0, wt_loss_pct=7.5	false
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=90.0, wt_loss_pct=7.5	true
derived: n_assessed	`known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced)`	intake_pct=80.0, wt_loss_pct=7.5, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown	5
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=chronic, a_sev_intake=False, a_sev_wt=False, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_sev_wt=False	0
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=chronic, a_sev_intake=False, a_mod_intake=False, a_sev_wt=False, a_mod_wt=True, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_mod_intake=False, c_sev_wt=False, c_mod_wt=True	3
outcome: severe	`n_severe >= 2`	n_severe=0	false
outcome: moderate	`n_moderate >= 2`	n_moderate=3	true

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=76, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=23.4, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=23.4, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=23.4, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=23.4, 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 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=37.3, 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=82.0, 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=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=10.62, t.wbc_hi=12, wbc_min_48h=5.62, 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=False, sirs_wbc=False	0
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=182.0	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=0.68	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=83.0	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=1.08	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=1.04	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=False, sofa_delta=0, t.sofa_delta=2	false
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=False, sirs_count=0, 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 (23)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-000298	Mon Jan 05, 2026 09:15 AM	creatinine	1.04 mg/dL
LAB-000299	Sun Oct 11, 2026 10:05 AM	creatinine	1.04 mg/dL
LAB-000300	Tue Nov 10, 2026 06:45 PM	creatinine	1.06 mg/dL
LAB-000304	Tue Nov 10, 2026 06:45 PM	sodium	141.0 mmol/L
LAB-000308	Tue Nov 10, 2026 06:45 PM	hemoglobin	13.37 g/dL
LAB-000312	Tue Nov 10, 2026 06:45 PM	wbc	5.62 x10^3/uL
LAB-000313	Tue Nov 10, 2026 06:45 PM	platelets	182.0 x10^3/uL
LAB-000320	Tue Nov 10, 2026 06:45 PM	bilirubin	0.68 mg/dL
LAB-000301	Wed Nov 11, 2026 05:00 AM	creatinine	1.03 mg/dL
LAB-000305	Wed Nov 11, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-000309	Wed Nov 11, 2026 05:00 AM	hemoglobin	11.48 g/dL
LAB-000314	Wed Nov 11, 2026 05:00 AM	wbc	10.62 x10^3/uL
LAB-000315	Wed Nov 11, 2026 05:00 AM	platelets	206.0 x10^3/uL
LAB-000302	Thu Nov 12, 2026 05:00 AM	creatinine	1.08 mg/dL
LAB-000306	Thu Nov 12, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-000310	Thu Nov 12, 2026 05:00 AM	hemoglobin	10.23 g/dL
LAB-000316	Thu Nov 12, 2026 05:00 AM	wbc	7.18 x10^3/uL
LAB-000317	Thu Nov 12, 2026 05:00 AM	platelets	274.0 x10^3/uL
LAB-000303	Fri Nov 13, 2026 05:00 AM	creatinine	1.05 mg/dL
LAB-000307	Fri Nov 13, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-000311	Fri Nov 13, 2026 05:00 AM	hemoglobin	11.03 g/dL
LAB-000318	Fri Nov 13, 2026 05:00 AM	wbc	8.44 x10^3/uL
LAB-000319	Fri Nov 13, 2026 05:00 AM	platelets	262.0 x10^3/uL

Vitals (54)

Vitals
Row	When	Kind	Value	Detail
VIT-000880	Tue Nov 10, 2026 06:05 PM	spo2	97.0	room air
VIT-000881	Tue Nov 10, 2026 06:05 PM	rr	19.0
VIT-000898	Tue Nov 10, 2026 06:05 PM	temp_c	36.8
VIT-000899	Tue Nov 10, 2026 06:05 PM	hr	82.0
VIT-000900	Tue Nov 10, 2026 06:05 PM	map	84.0
VIT-000901	Tue Nov 10, 2026 06:05 PM	gcs	15.0
VIT-000882	Wed Nov 11, 2026 02:05 AM	spo2	95.0	room air
VIT-000883	Wed Nov 11, 2026 02:05 AM	rr	20.0
VIT-000902	Wed Nov 11, 2026 02:05 AM	temp_c	36.9
VIT-000903	Wed Nov 11, 2026 02:05 AM	hr	78.0
VIT-000904	Wed Nov 11, 2026 02:05 AM	map	85.0
VIT-000905	Wed Nov 11, 2026 02:05 AM	gcs	15.0
VIT-000884	Wed Nov 11, 2026 10:05 AM	spo2	95.0	room air
VIT-000885	Wed Nov 11, 2026 10:05 AM	rr	17.0
VIT-000906	Wed Nov 11, 2026 10:05 AM	temp_c	37.0
VIT-000907	Wed Nov 11, 2026 10:05 AM	hr	78.0
VIT-000908	Wed Nov 11, 2026 10:05 AM	map	91.0
VIT-000909	Wed Nov 11, 2026 10:05 AM	gcs	15.0
VIT-000886	Wed Nov 11, 2026 06:05 PM	spo2	95.0	room air
VIT-000887	Wed Nov 11, 2026 06:05 PM	rr	14.0
VIT-000910	Wed Nov 11, 2026 06:05 PM	temp_c	37.3
VIT-000911	Wed Nov 11, 2026 06:05 PM	hr	80.0
VIT-000912	Wed Nov 11, 2026 06:05 PM	map	84.0
VIT-000913	Wed Nov 11, 2026 06:05 PM	gcs	15.0
VIT-000888	Thu Nov 12, 2026 02:05 AM	spo2	97.0	room air
VIT-000889	Thu Nov 12, 2026 02:05 AM	rr	17.0
VIT-000914	Thu Nov 12, 2026 02:05 AM	temp_c	37.2
VIT-000915	Thu Nov 12, 2026 02:05 AM	hr	78.0
VIT-000916	Thu Nov 12, 2026 02:05 AM	map	83.0
VIT-000917	Thu Nov 12, 2026 02:05 AM	gcs	15.0
VIT-000890	Thu Nov 12, 2026 10:05 AM	spo2	95.0	room air
VIT-000891	Thu Nov 12, 2026 10:05 AM	rr	14.0
VIT-000918	Thu Nov 12, 2026 10:05 AM	temp_c	36.7
VIT-000919	Thu Nov 12, 2026 10:05 AM	hr	79.0
VIT-000920	Thu Nov 12, 2026 10:05 AM	map	83.0
VIT-000921	Thu Nov 12, 2026 10:05 AM	gcs	15.0
VIT-000892	Thu Nov 12, 2026 06:05 PM	spo2	98.0	room air
VIT-000893	Thu Nov 12, 2026 06:05 PM	rr	18.0
VIT-000922	Thu Nov 12, 2026 06:05 PM	temp_c	37.6
VIT-000923	Thu Nov 12, 2026 06:05 PM	hr	68.0
VIT-000924	Thu Nov 12, 2026 06:05 PM	map	78.0
VIT-000925	Thu Nov 12, 2026 06:05 PM	gcs	15.0
VIT-000894	Fri Nov 13, 2026 02:05 AM	spo2	95.0	room air
VIT-000895	Fri Nov 13, 2026 02:05 AM	rr	18.0
VIT-000926	Fri Nov 13, 2026 02:05 AM	temp_c	36.8
VIT-000927	Fri Nov 13, 2026 02:05 AM	hr	79.0
VIT-000928	Fri Nov 13, 2026 02:05 AM	map	74.0
VIT-000929	Fri Nov 13, 2026 02:05 AM	gcs	15.0
VIT-000896	Fri Nov 13, 2026 10:05 AM	spo2	94.0	room air
VIT-000897	Fri Nov 13, 2026 10:05 AM	rr	17.0
VIT-000930	Fri Nov 13, 2026 10:05 AM	temp_c	37.1
VIT-000931	Fri Nov 13, 2026 10:05 AM	hr	81.0
VIT-000932	Fri Nov 13, 2026 10:05 AM	map	83.0
VIT-000933	Fri Nov 13, 2026 10:05 AM	gcs	15.0

Medications, orders, echo, history (1)

ORD-000008 11-11 09:00 transfusion_prbc: transfuse PRBC

Notes

History and physical · DOC-000031 · Dr. Noor Halvorsen (resident) · Tue Nov 10, 2026 08:45 PM

Cited facts from this note (1)

bleeding_source: coffee-ground emesis · cited p. 1, line 5 · confidence 0.85

Show source for bleeding_source

… ervice: Hospital Medicine Attending: Dr. Kenji Stavros History of present illness: 76-year-old man admitted with upper GI bleed. Presented after two days of coffee-ground emesis; GI consulted for endoscopy. Past medical history: hyperlipidemia. Review of systems otherwise negative. Exam: Lungs: clear to auscultation bilaterally. Assess …

Source document DOC-000031: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Marisol Okafor   MRN: MRN84006615   Admitted: 2026-11-10 17:45
Service: Hospital Medicine   Attending: Dr. Kenji Stavros

History of present illness: 76-year-old man admitted with upper GI bleed. Presented after two days of coffee-ground emesis; GI consulted for endoscopy.
Past medical history: hyperlipidemia.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Upper GI bleed: PPI, GI following.

Nutrition assessment · DOC-000030 · Vera Pemberton, RD (dietitian) · Wed Nov 11, 2026 08:45 PM

Cited facts from this note (8)

fat_loss: mild · cited p. 1, line 7 · confidence 0.90

Show source for fat_loss

… text: chronic illness Intake: estimated energy intake 80% of needs for 49 days. Weight history: 7.5% weight loss over 90 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
fluid_accumulation: none · cited p. 1, line 7 · confidence 0.90

Show source for fluid_accumulation

… e 80% of needs for 49 days. Weight history: 7.5% weight loss over 90 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
intake_days: 49 · cited p. 1, line 5 · confidence 0.95

Show source for intake_days

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Marisol Okafor MRN: MRN84006615 Context: chronic illness Intake: estimated energy intake 80% of needs for 49 days. Weight history: 7.5% weight loss over 90 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Rec …
intake_pct: 80 · cited p. 1, line 5 · confidence 0.95

Show source for intake_pct

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Marisol Okafor MRN: MRN84006615 Context: chronic illness Intake: estimated energy intake 80% of needs for 49 days. Weight history: 7.5% weight loss over 90 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Rec …
muscle_loss: mild · cited p. 1, line 7 · confidence 0.90

Show source for muscle_loss

… stimated energy intake 80% of needs for 49 days. Weight history: 7.5% weight loss over 90 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
nutrition_context: chronic · cited p. 1, line 4 · confidence 0.95

Show source for nutrition_context

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Marisol Okafor MRN: MRN84006615 Context: chronic illness Intake: estimated energy intake 80% of needs for 49 days. Weight history: 7.5% weight loss over 90 days. Nutrition-focused physical exam: mild loss of subcutan …
weight_loss_days: 90 · cited p. 1, line 6 · confidence 0.95

Show source for weight_loss_days

… tered Dietitian) Patient: Marisol Okafor MRN: MRN84006615 Context: chronic illness Intake: estimated energy intake 80% of needs for 49 days. Weight history: 7.5% weight loss over 90 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; cal …
weight_loss_pct: 7.5 · cited p. 1, line 6 · confidence 0.95

Show source for weight_loss_pct

… tered Dietitian) Patient: Marisol Okafor MRN: MRN84006615 Context: chronic illness Intake: estimated energy intake 80% of needs for 49 days. Weight history: 7.5% weight loss over 90 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; cal …

Source document DOC-000030: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Marisol Okafor   MRN: MRN84006615

Context: chronic illness
Intake: estimated energy intake 80% of needs for 49 days.
Weight history: 7.5% weight loss over 90 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Recommendations: high-protein oral supplement; calorie counts; weekly weights.

Progress note · DOC-000032 · Dr. Noor Halvorsen (resident) · Fri Nov 13, 2026 03:55 PM · awaiting cosign

Source document DOC-000032: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Marisol Okafor   MRN: MRN84006615   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Upper GI bleed: continue current management.
2. Malnourished: dietitian following.
3. Anemia: trend hemoglobin.

Resident: Dr. Noor Halvorsen   Attending cosign: pending