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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-00021: Sana Okafor

73F · MRN88500371 · Hospital Medicine · admitted Sat Oct 31, 2026 02:28 PM · discharged Sun Nov 08, 2026 03:44 PM · attending Dr. Isaac Abernath · resident Dr. Keira Upfield · 164 cm, 75.9 kg

Documented diagnoses (current)

  • Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
  • “GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis

Illustrative grouping now: MS-DRG 195 Simple pneumonia and pleurisy without CC/MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 195.

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=1.052, t.ratio_s1=1.5, creat_rise_48h=0.03, 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=1.052, t.ratio_s3=3.0, creat_peak=0.81, 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=1.052, 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=0.03, 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=13.11, 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=0.6, t.drop_major=2.0, prbc_units=0, t.prbc_major=2 false
outcome: met bleeding_documented and anaemic and acute_fall bleeding_documented=False, anaemic=False, acute_fall=False false
outcome: anaemia_only anaemic and hgb_drop < t.drop_min and prbc_units == 0 anaemic=False, hgb_drop=0.6, t.drop_min=1.0, prbc_units=0 false
outcome: not_anaemic present(hgb_nadir) and not anaemic hgb_nadir=13.11, 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=319, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=82.7, egfr_late=81.4 82.7
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=82.7, t.g2=60, egfr_late=81.4 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=82.7, 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=82.7, egfr_late=81.4, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=82.7, 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)
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=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)
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 Criteria not met No gap Not documented and not supported.
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=100.0, t.a_sev_intake_pct=50, intake_days=unknown, 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=100.0, t.a_mod_intake_pct=75, intake_days=unknown, 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=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=100.0, t.c_intake_pct=75, intake_days=unknown, 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=100.0, t.c_intake_pct=75, intake_days=unknown, 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=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=100.0, wt_loss_pct=unknown, fat_loss=0, muscle_loss=0, fluid=0, grip_reduced=unknown 4
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=acute, a_sev_intake=False, a_sev_wt=unknown, fat_loss=0, muscle_loss=0, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_sev_wt=unknown 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=acute, a_sev_intake=False, a_mod_intake=False, a_sev_wt=unknown, a_mod_wt=unknown, fat_loss=0, muscle_loss=0, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_mod_intake=False, c_sev_wt=unknown, c_mod_wt=unknown 0
outcome: severe n_severe >= 2 n_severe=0 false
outcome: moderate n_moderate >= 2 n_moderate=0 false
outcome: one_characteristic n_moderate == 1 n_moderate=0 false
outcome: not_met n_moderate == 0 and n_assessed >= 2 n_moderate=0, n_assessed=4 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)
StepExpressionInputs and thresholds readResult
outcome: not_adult age < t.adult age=73, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=28.2, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=28.2, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=28.2, t.c1=30 false
outcome: not_met bmi < t.c1 bmi=28.2, 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 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)
StepExpressionInputs and thresholds readResult
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)
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=37.4, t.t_hi=38, temp_min_48h=36.9, t.t_lo=36 false
derived: sirs_hr coalesce(hr_max_48h > t.hr, false) hr_max_48h=87.0, 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=18.0, 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=10.41, t.wbc_hi=12, wbc_min_48h=8.67, 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=222.0 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=0.82 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=0.8 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=0.77 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=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=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 (48)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-000692Sat Sep 27, 2025 09:15 AMcreatinine0.76 mg/dL
LAB-000693Wed Aug 12, 2026 10:05 AMcreatinine0.77 mg/dL
LAB-000694Sat Oct 31, 2026 03:28 PMcreatinine0.77 mg/dL
LAB-000703Sat Oct 31, 2026 03:28 PMsodium140.0 mmol/L
LAB-000712Sat Oct 31, 2026 03:28 PMhemoglobin13.33 g/dL
LAB-000721Sat Oct 31, 2026 03:28 PMwbc10.01 x10^3/uL
LAB-000722Sat Oct 31, 2026 03:28 PMplatelets297.0 x10^3/uL
LAB-000739Sat Oct 31, 2026 03:28 PMbilirubin0.82 mg/dL
LAB-000695Sun Nov 01, 2026 05:00 AMcreatinine0.78 mg/dL
LAB-000704Sun Nov 01, 2026 05:00 AMsodium139.0 mmol/L
LAB-000713Sun Nov 01, 2026 05:00 AMhemoglobin13.5 g/dL
LAB-000723Sun Nov 01, 2026 05:00 AMwbc8.67 x10^3/uL
LAB-000724Sun Nov 01, 2026 05:00 AMplatelets222.0 x10^3/uL
LAB-000696Mon Nov 02, 2026 05:00 AMcreatinine0.8 mg/dL
LAB-000705Mon Nov 02, 2026 05:00 AMsodium140.0 mmol/L
LAB-000714Mon Nov 02, 2026 05:00 AMhemoglobin13.67 g/dL
LAB-000725Mon Nov 02, 2026 05:00 AMwbc10.41 x10^3/uL
LAB-000726Mon Nov 02, 2026 05:00 AMplatelets293.0 x10^3/uL
LAB-000697Tue Nov 03, 2026 05:00 AMcreatinine0.77 mg/dL
LAB-000706Tue Nov 03, 2026 05:00 AMsodium139.0 mmol/L
LAB-000715Tue Nov 03, 2026 05:00 AMhemoglobin13.53 g/dL
LAB-000727Tue Nov 03, 2026 05:00 AMwbc7.81 x10^3/uL
LAB-000728Tue Nov 03, 2026 05:00 AMplatelets285.0 x10^3/uL
LAB-000698Wed Nov 04, 2026 05:00 AMcreatinine0.8 mg/dL
LAB-000707Wed Nov 04, 2026 05:00 AMsodium140.0 mmol/L
LAB-000716Wed Nov 04, 2026 05:00 AMhemoglobin13.21 g/dL
LAB-000729Wed Nov 04, 2026 05:00 AMwbc8.04 x10^3/uL
LAB-000730Wed Nov 04, 2026 05:00 AMplatelets177.0 x10^3/uL
LAB-000699Thu Nov 05, 2026 05:00 AMcreatinine0.8 mg/dL
LAB-000708Thu Nov 05, 2026 05:00 AMsodium136.0 mmol/L
LAB-000717Thu Nov 05, 2026 05:00 AMhemoglobin13.44 g/dL
LAB-000731Thu Nov 05, 2026 05:00 AMwbc10.33 x10^3/uL
LAB-000732Thu Nov 05, 2026 05:00 AMplatelets261.0 x10^3/uL
LAB-000700Fri Nov 06, 2026 05:00 AMcreatinine0.81 mg/dL
LAB-000709Fri Nov 06, 2026 05:00 AMsodium136.0 mmol/L
LAB-000718Fri Nov 06, 2026 05:00 AMhemoglobin13.11 g/dL
LAB-000733Fri Nov 06, 2026 05:00 AMwbc8.4 x10^3/uL
LAB-000734Fri Nov 06, 2026 05:00 AMplatelets173.0 x10^3/uL
LAB-000701Sat Nov 07, 2026 05:00 AMcreatinine0.77 mg/dL
LAB-000710Sat Nov 07, 2026 05:00 AMsodium141.0 mmol/L
LAB-000719Sat Nov 07, 2026 05:00 AMhemoglobin13.24 g/dL
LAB-000735Sat Nov 07, 2026 05:00 AMwbc7.3 x10^3/uL
LAB-000736Sat Nov 07, 2026 05:00 AMplatelets227.0 x10^3/uL
LAB-000702Sun Nov 08, 2026 05:00 AMcreatinine0.79 mg/dL
LAB-000711Sun Nov 08, 2026 05:00 AMsodium136.0 mmol/L
LAB-000720Sun Nov 08, 2026 05:00 AMhemoglobin13.17 g/dL
LAB-000737Sun Nov 08, 2026 05:00 AMwbc7.08 x10^3/uL
LAB-000738Sun Nov 08, 2026 05:00 AMplatelets182.0 x10^3/uL
Vitals (150)
Vitals
RowWhenKindValueDetail
VIT-001968Sat Oct 31, 2026 02:48 PMspo296.0room air
VIT-001969Sat Oct 31, 2026 02:48 PMrr14.0
VIT-002018Sat Oct 31, 2026 02:48 PMtemp_c37.4
VIT-002019Sat Oct 31, 2026 02:48 PMhr84.0
VIT-002020Sat Oct 31, 2026 02:48 PMmap78.0
VIT-002021Sat Oct 31, 2026 02:48 PMgcs15.0
VIT-001970Sat Oct 31, 2026 10:48 PMspo295.0room air
VIT-001971Sat Oct 31, 2026 10:48 PMrr16.0
VIT-002022Sat Oct 31, 2026 10:48 PMtemp_c36.9
VIT-002023Sat Oct 31, 2026 10:48 PMhr87.0
VIT-002024Sat Oct 31, 2026 10:48 PMmap84.0
VIT-002025Sat Oct 31, 2026 10:48 PMgcs15.0
VIT-001972Sun Nov 01, 2026 06:48 AMspo299.0room air
VIT-001973Sun Nov 01, 2026 06:48 AMrr17.0
VIT-002026Sun Nov 01, 2026 06:48 AMtemp_c37.4
VIT-002027Sun Nov 01, 2026 06:48 AMhr74.0
VIT-002028Sun Nov 01, 2026 06:48 AMmap86.0
VIT-002029Sun Nov 01, 2026 06:48 AMgcs15.0
VIT-001974Sun Nov 01, 2026 02:48 PMspo295.0room air
VIT-001975Sun Nov 01, 2026 02:48 PMrr14.0
VIT-002030Sun Nov 01, 2026 02:48 PMtemp_c37.2
VIT-002031Sun Nov 01, 2026 02:48 PMhr82.0
VIT-002032Sun Nov 01, 2026 02:48 PMmap74.0
VIT-002033Sun Nov 01, 2026 02:48 PMgcs15.0
VIT-001976Sun Nov 01, 2026 10:48 PMspo294.0room air
VIT-001977Sun Nov 01, 2026 10:48 PMrr18.0
VIT-002034Sun Nov 01, 2026 10:48 PMtemp_c37.3
VIT-002035Sun Nov 01, 2026 10:48 PMhr82.0
VIT-002036Sun Nov 01, 2026 10:48 PMmap85.0
VIT-002037Sun Nov 01, 2026 10:48 PMgcs15.0
VIT-001978Mon Nov 02, 2026 06:48 AMspo295.0room air
VIT-001979Mon Nov 02, 2026 06:48 AMrr16.0
VIT-002038Mon Nov 02, 2026 06:48 AMtemp_c36.9
VIT-002039Mon Nov 02, 2026 06:48 AMhr74.0
VIT-002040Mon Nov 02, 2026 06:48 AMmap74.0
VIT-002041Mon Nov 02, 2026 06:48 AMgcs15.0
VIT-001980Mon Nov 02, 2026 02:48 PMspo297.0room air
VIT-001981Mon Nov 02, 2026 02:48 PMrr18.0
VIT-002042Mon Nov 02, 2026 02:48 PMtemp_c36.9
VIT-002043Mon Nov 02, 2026 02:48 PMhr73.0
VIT-002044Mon Nov 02, 2026 02:48 PMmap82.0
VIT-002045Mon Nov 02, 2026 02:48 PMgcs15.0
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Medications, orders, echo, history (4)

Notes

History and physical · DOC-000069 · Dr. Keira Upfield (resident) · Sat Oct 31, 2026 05:28 PM

Cited facts from this note (1)
infection_source
multifocal pneumonia · cited p. 1, line 5 · confidence 0.85
Show source for infection_source
… Hospital Medicine Attending: Dr. Isaac Abernath History of present illness: 73-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: GERD. Review of systems otherwise negative. Exam: Lungs: clear to auscultation bilaterally …
Source document DOC-000069: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Sana Okafor   MRN: MRN88500371   Admitted: 2026-10-31 14:28
Service: Hospital Medicine   Attending: Dr. Isaac Abernath

History of present illness: 73-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: GERD.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Nutrition assessment · DOC-000068 · Vera Pemberton, RD (dietitian) · Sun Nov 01, 2026 08:28 PM

Cited facts from this note (5)
fat_loss
none · cited p. 1, line 7 · confidence 0.90
Show source for fat_loss
… MRN: MRN88500371 Context: acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: well nourished; no malnutrition identified.
fluid_accumulation
none · cited p. 1, line 7 · confidence 0.90
Show source for fluid_accumulation
… e: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: well nourished; no malnutrition identified.
intake_pct
100 · cited p. 1, line 5 · confidence 0.90
Show source for intake_pct
NUTRITION ASSESSMENT (Registered Dietitian) Patient: Sana Okafor MRN: MRN88500371 Context: acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. …
muscle_loss
none · cited p. 1, line 7 · confidence 0.90
Show source for muscle_loss
… acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: well nourished; no malnutrition identified.
nutrition_context
acute · cited p. 1, line 4 · confidence 0.95
Show source for nutrition_context
NUTRITION ASSESSMENT (Registered Dietitian) Patient: Sana Okafor MRN: MRN88500371 Context: acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle was …
Source document DOC-000068: Nutrition assessment (synthetic)
NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Sana Okafor   MRN: MRN88500371

Context: acute illness
Intake: eating 100% of meals.
Weight history: weight stable over the past 3 months.
Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation.
Assessment: well nourished; no malnutrition identified.

Progress note · DOC-000070 · Dr. Keira Upfield (resident) · Mon Nov 02, 2026 03:28 PM

Source document DOC-000070: Progress note (synthetic)
PROGRESS NOTE (Resident)
Patient: Sana Okafor   MRN: MRN88500371   Hospital day 3

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

Resident: Dr. Keira Upfield   Attending cosign: completed

Discharge summary · DOC-000071 · Dr. Isaac Abernath (attending) · Sun Nov 08, 2026 03:44 PM

Source document DOC-000071: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Sana Okafor   MRN: MRN88500371
Admitted 2026-10-31; discharged 2026-11-08.

Discharge diagnoses:
- community-acquired pneumonia
- GERD

Disposition: home with follow-up.