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Exact Dx synthetic data · demonstration
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.

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ENC-00011: Uma Greaves

61F · MRN51997268 · Hospital Medicine · admitted Tue Oct 27, 2026 05:17 PM · discharged Mon Nov 02, 2026 11:24 AM · attending Dr. Jalen Carrow · 153 cm, 54.4 kg

Documented diagnoses (current)

  • Principal: “sepsis” · A41.9 Sepsis, unspecified organism
  • “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
  • “hypoxia” · R09.02 Hypoxemia
  • “hyperlipidemia” · E78.5 Hyperlipidemia, unspecified
  • “hypertension” · I10 Essential (primary) hypertension

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

Every rule's outcome for this encounter (clean results included)
RuleCriteriaFindingOutcome
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)
StepExpressionInputs and thresholds readResult
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=1.062, 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=1.062, t.ratio_s3=3.0, creat_peak=0.85, 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=1.062, 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 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)
StepExpressionInputs and thresholds readResult
derived: anaemic case(sex == 'M', hgb_nadir < t.hb_m, sex == 'F', hgb_nadir < t.hb_f, null) sex=F, hgb_nadir=13.43, 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=13.43, 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)
StepExpressionInputs and thresholds readResult
derived: chronic egfr_n >= 2 and egfr_span_days >= t.chronic_days egfr_n=2, egfr_span_days=199, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=82.5, egfr_late=83.8 83.8
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=82.5, t.g2=60, egfr_late=83.8 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=83.8, 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=82.5, egfr_late=83.8, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=83.8, 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)
StepExpressionInputs and thresholds readResult
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)
StepExpressionInputs and thresholds readResult
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)
StepExpressionInputs and thresholds readResult
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)
StepExpressionInputs and thresholds readResult
outcome: not_adult age < t.adult age=61, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=23.2, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=23.2, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=23.2, t.c1=30 false
outcome: not_met bmi < t.c1 bmi=23.2, t.c1=30 true
Pressure injury Insufficient data No gap Insufficient data: the criteria could not be applied.
Trace
Rule trace (rule pressure_injury v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
StepExpressionInputs and thresholds readResult
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)
StepExpressionInputs and thresholds readResult
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=32.0, 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 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)
StepExpressionInputs and thresholds readResult
derived: sirs_temp coalesce(temp_max_48h > t.t_hi, false) or coalesce(temp_min_48h < t.t_lo, false) temp_max_48h=39.1, t.t_hi=38, temp_min_48h=38.5, t.t_lo=36 true
derived: sirs_hr coalesce(hr_max_48h > t.hr, false) hr_max_48h=122.0, t.hr=90 true
derived: sirs_rr coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false) rr_max_48h=32.0, 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=18.69, t.wbc_hi=12, wbc_min_48h=16.15, 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=True, sirs_wbc=True 4
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=85.0 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=0.85 0
derived: sofa_cardio coalesce(case(norepi_max_48h > 0.1, 4, norepi_max_48h > 0, 3, map_min_48h < 70, 1, 0), 0) norepi_max_48h=0.0, map_min_48h=64.0 1
derived: sofa_cns coalesce(case(gcs_min_48h < 6, 4, gcs_min_48h < 10, 3, gcs_min_48h < 13, 2, gcs_min_48h < 15, 1, 0), 0) gcs_min_48h=15.0 0
derived: sofa_renal coalesce(case(creat_max_48h >= 5, 4, creat_max_48h >= 3.5, 3, creat_max_48h >= 2, 2, creat_max_48h >= 1.2, 1, 0), 0) creat_max_48h=0.85 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=0.8 0
derived: sofa_delta sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline sofa_resp=2, sofa_coag=2, sofa_liver=0, sofa_cardio=1, sofa_cns=0, sofa_renal=0, sofa_renal_baseline=0 5
derived: sepsis3 infection_documented and sofa_delta >= t.sofa_delta infection_documented=True, sofa_delta=5, t.sofa_delta=2 true
derived: sepsis2 infection_documented and sirs_count >= t.sirs_min infection_documented=True, sirs_count=4, 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=2.37, 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 (41)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-000349Sun Dec 21, 2025 09:15 AMcreatinine0.81 mg/dL
LAB-000350Thu Jul 09, 2026 10:05 AMcreatinine0.8 mg/dL
LAB-000358Tue Oct 27, 2026 05:42 PMpao252.0 mmHg
LAB-000359Tue Oct 27, 2026 05:42 PMfio221.0 %
LAB-000351Tue Oct 27, 2026 06:17 PMcreatinine0.85 mg/dL
LAB-000360Tue Oct 27, 2026 06:17 PMsodium138.0 mmol/L
LAB-000367Tue Oct 27, 2026 06:17 PMhemoglobin13.49 g/dL
LAB-000374Tue Oct 27, 2026 06:17 PMwbc18.69 x10^3/uL
LAB-000375Tue Oct 27, 2026 06:17 PMplatelets94.0 x10^3/uL
LAB-000388Tue Oct 27, 2026 06:17 PMbilirubin0.85 mg/dL
LAB-000389Tue Oct 27, 2026 06:17 PMlactate2.37 mmol/L
LAB-000352Wed Oct 28, 2026 05:00 AMcreatinine0.79 mg/dL
LAB-000361Wed Oct 28, 2026 05:00 AMsodium139.0 mmol/L
LAB-000368Wed Oct 28, 2026 05:00 AMhemoglobin13.62 g/dL
LAB-000376Wed Oct 28, 2026 05:00 AMwbc16.99 x10^3/uL
LAB-000377Wed Oct 28, 2026 05:00 AMplatelets95.0 x10^3/uL
LAB-000353Thu Oct 29, 2026 05:00 AMcreatinine0.82 mg/dL
LAB-000362Thu Oct 29, 2026 05:00 AMsodium140.0 mmol/L
LAB-000369Thu Oct 29, 2026 05:00 AMhemoglobin13.44 g/dL
LAB-000378Thu Oct 29, 2026 05:00 AMwbc16.15 x10^3/uL
LAB-000379Thu Oct 29, 2026 05:00 AMplatelets85.0 x10^3/uL
LAB-000354Fri Oct 30, 2026 05:00 AMcreatinine0.79 mg/dL
LAB-000363Fri Oct 30, 2026 05:00 AMsodium136.0 mmol/L
LAB-000370Fri Oct 30, 2026 05:00 AMhemoglobin13.45 g/dL
LAB-000380Fri Oct 30, 2026 05:00 AMwbc10.62 x10^3/uL
LAB-000381Fri Oct 30, 2026 05:00 AMplatelets264.0 x10^3/uL
LAB-000355Sat Oct 31, 2026 05:00 AMcreatinine0.84 mg/dL
LAB-000364Sat Oct 31, 2026 05:00 AMsodium140.0 mmol/L
LAB-000371Sat Oct 31, 2026 05:00 AMhemoglobin13.43 g/dL
LAB-000382Sat Oct 31, 2026 05:00 AMwbc5.63 x10^3/uL
LAB-000383Sat Oct 31, 2026 05:00 AMplatelets184.0 x10^3/uL
LAB-000356Sun Nov 01, 2026 05:00 AMcreatinine0.84 mg/dL
LAB-000365Sun Nov 01, 2026 05:00 AMsodium140.0 mmol/L
LAB-000372Sun Nov 01, 2026 05:00 AMhemoglobin13.55 g/dL
LAB-000384Sun Nov 01, 2026 05:00 AMwbc8.15 x10^3/uL
LAB-000385Sun Nov 01, 2026 05:00 AMplatelets224.0 x10^3/uL
LAB-000357Mon Nov 02, 2026 05:00 AMcreatinine0.83 mg/dL
LAB-000366Mon Nov 02, 2026 05:00 AMsodium138.0 mmol/L
LAB-000373Mon Nov 02, 2026 05:00 AMhemoglobin13.71 g/dL
LAB-000386Mon Nov 02, 2026 05:00 AMwbc9.76 x10^3/uL
LAB-000387Mon Nov 02, 2026 05:00 AMplatelets297.0 x10^3/uL
Vitals (126)
Vitals
RowWhenKindValueDetail
VIT-001006Tue Oct 27, 2026 05:37 PMspo285.0room air
VIT-001007Tue Oct 27, 2026 05:37 PMrr32.0
VIT-001060Tue Oct 27, 2026 05:37 PMtemp_c38.8
VIT-001061Tue Oct 27, 2026 05:37 PMhr122.0
VIT-001062Tue Oct 27, 2026 05:37 PMmap64.0
VIT-001063Tue Oct 27, 2026 05:37 PMgcs15.0
VIT-001008Tue Oct 27, 2026 05:47 PMo2_lpm6.0nasal cannula
VIT-001009Wed Oct 28, 2026 01:37 AMspo294.0nasal cannula
VIT-001010Wed Oct 28, 2026 01:37 AMrr25.0
VIT-001011Wed Oct 28, 2026 01:37 AMo2_lpm3.0nasal cannula
VIT-001064Wed Oct 28, 2026 01:37 AMtemp_c38.8
VIT-001065Wed Oct 28, 2026 01:37 AMhr121.0
VIT-001066Wed Oct 28, 2026 01:37 AMmap65.0
VIT-001067Wed Oct 28, 2026 01:37 AMgcs15.0
VIT-001012Wed Oct 28, 2026 09:37 AMspo295.0nasal cannula
VIT-001013Wed Oct 28, 2026 09:37 AMrr21.0
VIT-001014Wed Oct 28, 2026 09:37 AMo2_lpm3.0nasal cannula
VIT-001068Wed Oct 28, 2026 09:37 AMtemp_c38.9
VIT-001069Wed Oct 28, 2026 09:37 AMhr106.0
VIT-001070Wed Oct 28, 2026 09:37 AMmap65.0
VIT-001071Wed Oct 28, 2026 09:37 AMgcs15.0
VIT-001015Wed Oct 28, 2026 05:37 PMspo293.0nasal cannula
VIT-001016Wed Oct 28, 2026 05:37 PMrr20.0
VIT-001017Wed Oct 28, 2026 05:37 PMo2_lpm2.0nasal cannula
VIT-001072Wed Oct 28, 2026 05:37 PMtemp_c39.1
VIT-001073Wed Oct 28, 2026 05:37 PMhr103.0
VIT-001074Wed Oct 28, 2026 05:37 PMmap68.0
VIT-001075Wed Oct 28, 2026 05:37 PMgcs15.0
VIT-001018Thu Oct 29, 2026 01:37 AMspo293.0nasal cannula
VIT-001019Thu Oct 29, 2026 01:37 AMrr24.0
VIT-001020Thu Oct 29, 2026 01:37 AMo2_lpm2.0nasal cannula
VIT-001076Thu Oct 29, 2026 01:37 AMtemp_c38.5
VIT-001077Thu Oct 29, 2026 01:37 AMhr109.0
VIT-001078Thu Oct 29, 2026 01:37 AMmap64.0
VIT-001079Thu Oct 29, 2026 01:37 AMgcs15.0
VIT-001021Thu Oct 29, 2026 09:37 AMspo295.0nasal cannula
VIT-001022Thu Oct 29, 2026 09:37 AMrr21.0
VIT-001023Thu Oct 29, 2026 09:37 AMo2_lpm3.0nasal cannula
VIT-001080Thu Oct 29, 2026 09:37 AMtemp_c38.9
VIT-001081Thu Oct 29, 2026 09:37 AMhr103.0
VIT-001082Thu Oct 29, 2026 09:37 AMmap68.0
VIT-001083Thu Oct 29, 2026 09:37 AMgcs15.0
VIT-001024Thu Oct 29, 2026 05:37 PMspo295.0nasal cannula
VIT-001025Thu Oct 29, 2026 05:37 PMrr21.0
VIT-001026Thu Oct 29, 2026 05:37 PMo2_lpm2.0nasal cannula
VIT-001084Thu Oct 29, 2026 05:37 PMtemp_c36.6
VIT-001085Thu Oct 29, 2026 05:37 PMhr90.0
VIT-001086Thu Oct 29, 2026 05:37 PMmap79.0
VIT-001087Thu Oct 29, 2026 05:37 PMgcs15.0
VIT-001027Fri Oct 30, 2026 01:37 AMspo294.0nasal cannula
VIT-001028Fri Oct 30, 2026 01:37 AMrr24.0
VIT-001029Fri Oct 30, 2026 01:37 AMo2_lpm4.0nasal cannula
VIT-001088Fri Oct 30, 2026 01:37 AMtemp_c37.2
VIT-001089Fri Oct 30, 2026 01:37 AMhr75.0
VIT-001090Fri Oct 30, 2026 01:37 AMmap79.0
VIT-001091Fri Oct 30, 2026 01:37 AMgcs15.0
VIT-001030Fri Oct 30, 2026 09:37 AMspo293.0nasal cannula
VIT-001031Fri Oct 30, 2026 09:37 AMrr26.0
VIT-001032Fri Oct 30, 2026 09:37 AMo2_lpm3.0nasal cannula
VIT-001092Fri Oct 30, 2026 09:37 AMtemp_c36.7
VIT-001093Fri Oct 30, 2026 09:37 AMhr83.0
VIT-001094Fri Oct 30, 2026 09:37 AMmap83.0
VIT-001095Fri Oct 30, 2026 09:37 AMgcs15.0
VIT-001033Fri Oct 30, 2026 05:37 PMspo294.0nasal cannula
VIT-001034Fri Oct 30, 2026 05:37 PMrr22.0
VIT-001035Fri Oct 30, 2026 05:37 PMo2_lpm4.0nasal cannula
VIT-001096Fri Oct 30, 2026 05:37 PMtemp_c37.3
VIT-001097Fri Oct 30, 2026 05:37 PMhr70.0
VIT-001098Fri Oct 30, 2026 05:37 PMmap74.0
VIT-001099Fri Oct 30, 2026 05:37 PMgcs15.0
VIT-001036Sat Oct 31, 2026 01:37 AMspo294.0nasal cannula
VIT-001037Sat Oct 31, 2026 01:37 AMrr25.0
VIT-001038Sat Oct 31, 2026 01:37 AMo2_lpm3.0nasal cannula
VIT-001100Sat Oct 31, 2026 01:37 AMtemp_c37.1
VIT-001101Sat Oct 31, 2026 01:37 AMhr78.0
VIT-001102Sat Oct 31, 2026 01:37 AMmap76.0
VIT-001103Sat Oct 31, 2026 01:37 AMgcs15.0
VIT-001039Sat Oct 31, 2026 09:37 AMspo294.0nasal cannula
VIT-001040Sat Oct 31, 2026 09:37 AMrr25.0
VIT-001041Sat Oct 31, 2026 09:37 AMo2_lpm2.0nasal cannula
VIT-001104Sat Oct 31, 2026 09:37 AMtemp_c36.9
VIT-001105Sat Oct 31, 2026 09:37 AMhr81.0
VIT-001106Sat Oct 31, 2026 09:37 AMmap83.0
VIT-001107Sat Oct 31, 2026 09:37 AMgcs15.0
VIT-001042Sat Oct 31, 2026 05:37 PMspo295.0nasal cannula
VIT-001043Sat Oct 31, 2026 05:37 PMrr21.0
VIT-001044Sat Oct 31, 2026 05:37 PMo2_lpm2.0nasal cannula
VIT-001108Sat Oct 31, 2026 05:37 PMtemp_c37.4
VIT-001109Sat Oct 31, 2026 05:37 PMhr92.0
VIT-001110Sat Oct 31, 2026 05:37 PMmap86.0
VIT-001111Sat Oct 31, 2026 05:37 PMgcs15.0
VIT-001045Sun Nov 01, 2026 01:37 AMspo293.0nasal cannula
VIT-001046Sun Nov 01, 2026 01:37 AMrr25.0
VIT-001047Sun Nov 01, 2026 01:37 AMo2_lpm3.0nasal cannula
VIT-001112Sun Nov 01, 2026 01:37 AMtemp_c37.2
VIT-001113Sun Nov 01, 2026 01:37 AMhr73.0
VIT-001114Sun Nov 01, 2026 01:37 AMmap89.0
VIT-001115Sun Nov 01, 2026 01:37 AMgcs15.0
VIT-001048Sun Nov 01, 2026 09:37 AMspo292.0nasal cannula
VIT-001049Sun Nov 01, 2026 09:37 AMrr20.0
VIT-001050Sun Nov 01, 2026 09:37 AMo2_lpm4.0nasal cannula
VIT-001116Sun Nov 01, 2026 09:37 AMtemp_c37.4
VIT-001117Sun Nov 01, 2026 09:37 AMhr88.0
VIT-001118Sun Nov 01, 2026 09:37 AMmap80.0
VIT-001119Sun Nov 01, 2026 09:37 AMgcs15.0
VIT-001051Sun Nov 01, 2026 05:37 PMspo293.0nasal cannula
VIT-001052Sun Nov 01, 2026 05:37 PMrr24.0
VIT-001053Sun Nov 01, 2026 05:37 PMo2_lpm4.0nasal cannula
VIT-001120Sun Nov 01, 2026 05:37 PMtemp_c36.6
VIT-001121Sun Nov 01, 2026 05:37 PMhr87.0
VIT-001122Sun Nov 01, 2026 05:37 PMmap80.0
VIT-001123Sun Nov 01, 2026 05:37 PMgcs15.0
VIT-001054Mon Nov 02, 2026 01:37 AMspo295.0nasal cannula
VIT-001055Mon Nov 02, 2026 01:37 AMrr26.0
VIT-001056Mon Nov 02, 2026 01:37 AMo2_lpm2.0nasal cannula
VIT-001124Mon Nov 02, 2026 01:37 AMtemp_c36.6
VIT-001125Mon Nov 02, 2026 01:37 AMhr72.0
VIT-001126Mon Nov 02, 2026 01:37 AMmap76.0
VIT-001127Mon Nov 02, 2026 01:37 AMgcs15.0
VIT-001057Mon Nov 02, 2026 09:37 AMspo292.0nasal cannula
VIT-001058Mon Nov 02, 2026 09:37 AMrr24.0
VIT-001059Mon Nov 02, 2026 09:37 AMo2_lpm4.0nasal cannula
VIT-001128Mon Nov 02, 2026 09:37 AMtemp_c36.6
VIT-001129Mon Nov 02, 2026 09:37 AMhr80.0
VIT-001130Mon Nov 02, 2026 09:37 AMmap84.0
VIT-001131Mon Nov 02, 2026 09:37 AMgcs15.0
Medications, orders, echo, history (4)

Notes

History and physical · DOC-000036 · Dr. Jalen Carrow (attending) · Tue Oct 27, 2026 08:17 PM

Cited facts from this note (3)
bleeding_source
bleeding · cited p. 1, line 7 · confidence 0.50
Show source for bleeding_source
… h sepsis. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: hyperlipidemia, hypertension. Denies bleeding, chest pain or fever. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. Sepsis: antibiotics, fluids. 2. Community-acq …
infection_source
left lower lobe pneumonia · cited p. 1, line 5 · confidence 0.85
Show source for infection_source
… 026-10-27 17:17 Service: Hospital Medicine Attending: Dr. Jalen Carrow History of present illness: 61-year-old woman admitted with sepsis. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: hyperlipidemia, hypertension. Denies bleeding, chest pain or fever. Exam: Lungs: increased …
work_of_breathing
increased · cited p. 1, line 8 · confidence 0.90
Show source for work_of_breathing
… pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: hyperlipidemia, hypertension. Denies bleeding, chest pain or fever. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. Sepsis: antibiotics, fluids. 2. Community-acquired pneumonia: antibiotics.
Source document DOC-000036: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Uma Greaves   MRN: MRN51997268   Admitted: 2026-10-27 17:17
Service: Hospital Medicine   Attending: Dr. Jalen Carrow

History of present illness: 61-year-old woman admitted with sepsis. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: hyperlipidemia, hypertension.
Denies bleeding, chest pain or fever.
Exam: Lungs: increased work of breathing with accessory muscle use.
Assessment and plan:
1. Sepsis: antibiotics, fluids.
2. Community-acquired pneumonia: antibiotics.

Progress note · DOC-000037 · Dr. Jalen Carrow (attending) · Thu Oct 29, 2026 07:17 PM

Source document DOC-000037: Progress note (synthetic)
PROGRESS NOTE (Attending)
Patient: Uma Greaves   MRN: MRN51997268   Hospital day 3

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

Attending: Dr. Jalen Carrow

Discharge summary · DOC-000038 · Dr. Jalen Carrow (attending) · Mon Nov 02, 2026 11:24 AM

Source document DOC-000038: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Uma Greaves   MRN: MRN51997268
Admitted 2026-10-27; discharged 2026-11-02.

Discharge diagnoses:
- sepsis
- community-acquired pneumonia
- hypoxia
- hyperlipidemia
- hypertension

Disposition: home with follow-up.