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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-00026: Jalen Sallow

63F · MRN13637762 · Hospital Medicine · admitted Mon Oct 26, 2026 10:09 AM · discharged Tue Nov 03, 2026 04:03 PM · attending Dr. Cyrus Ellingham · resident Dr. Greta Kowalczyk · 159 cm, 42.6 kg

Documented diagnoses (current)

  • Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
  • “severe protein-calorie malnutrition” · E43 Unspecified severe protein-calorie malnutrition
  • “CKD stage 3a” · N18.31 Chronic kidney disease, stage 3a
  • “CHF” · I50.9 Heart failure, unspecified
  • “hypertension” · I10 Essential (primary) hypertension
  • “hyperlipidemia” · E78.5 Hyperlipidemia, unspecified
  • “type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications

Illustrative grouping now: MS-DRG 193 Simple pneumonia and pleurisy with MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 194.

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=1.041, t.ratio_s1=1.5, creat_rise_48h=0.06, 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=1.041, t.ratio_s3=3.0, creat_peak=1.26, 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=1.041, 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=0.06, 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=12.58, 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=0.5, 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=0.5, t.drop_min=1.0, prbc_units=0 false
outcome: not_anaemic present(hgb_nadir) and not anaemic hgb_nadir=12.58, anaemic=False true
Chronic kidney disease Criteria met No gap Supported as documented (N18.31).
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=280, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=53.0, egfr_late=50.4 53.0
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=53.0, t.g2=60, egfr_late=50.4 true
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=53.0, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15 G3a
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=True, egfr_early=53.0, egfr_late=50.4, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=53.0, t.g2=60 false
outcome: g3a category == 'G3a' category=G3a true
Heart failure Criteria met Specificity gap Documented “CHF” (I50.9); criteria support the more specific Chronic diastolic (HFpEF) heart failure (I50.32).
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=72.0, 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=63.0, 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=63.0, 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=0, hf_history=True 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=chronic false
outcome: sys_acute hf_type == 'systolic' and acuity == 'acute' hf_type=diastolic, acuity=chronic false
outcome: sys_chronic hf_type == 'systolic' and acuity == 'chronic' hf_type=diastolic, acuity=chronic false
outcome: dia_aoc hf_type == 'diastolic' and acuity == 'acute on chronic' hf_type=diastolic, acuity=chronic false
outcome: dia_acute hf_type == 'diastolic' and acuity == 'acute' hf_type=diastolic, acuity=chronic false
outcome: dia_chronic hf_type == 'diastolic' and acuity == 'chronic' hf_type=diastolic, acuity=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)
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 met Clinical validation gap Documented “severe protein-calorie malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (acute illness context), E44.0).
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=60.0, t.a_sev_intake_pct=50, intake_days=11.0, 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=60.0, t.a_mod_intake_pct=75, intake_days=11.0, t.a_mod_intake_days=7 true
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=30.0, wt_loss_pct=3.0 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=30.0, wt_loss_pct=3.0 false
derived: c_sev_intake intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days intake_pct=60.0, t.c_intake_pct=75, intake_days=11.0, 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=60.0, t.c_intake_pct=75, intake_days=11.0, 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=30.0, wt_loss_pct=3.0 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=30.0, wt_loss_pct=3.0 false
derived: n_assessed known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced) intake_pct=60.0, wt_loss_pct=3.0, 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=acute, 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=acute, a_sev_intake=False, a_mod_intake=True, a_sev_wt=False, a_mod_wt=False, 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=False 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)
StepExpressionInputs and thresholds readResult
outcome: not_adult age < t.adult age=63, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=16.9, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=16.9, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=16.9, t.c1=30 false
outcome: not_met bmi < t.c1 bmi=16.9, 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=37.5, t.t_hi=38, temp_min_48h=36.6, t.t_lo=36 false
derived: sirs_hr coalesce(hr_max_48h > t.hr, false) hr_max_48h=89.0, t.hr=90 false
derived: sirs_rr coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false) rr_max_48h=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=10.47, t.wbc_hi=12, wbc_min_48h=8.33, 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=200.0 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=0.7 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=78.0 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=1.25 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=1.21 1
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=1, sofa_renal_baseline=1 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 (49)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-000873Tue Oct 14, 2025 09:15 AMcreatinine1.16 mg/dL
LAB-000874Tue Jul 21, 2026 10:05 AMcreatinine1.21 mg/dL
LAB-000875Mon Oct 26, 2026 11:09 AMcreatinine1.24 mg/dL
LAB-000884Mon Oct 26, 2026 11:09 AMbnp72.0 pg/mL
LAB-000885Mon Oct 26, 2026 11:09 AMsodium140.0 mmol/L
LAB-000894Mon Oct 26, 2026 11:09 AMhemoglobin12.83 g/dL
LAB-000903Mon Oct 26, 2026 11:09 AMwbc10.47 x10^3/uL
LAB-000904Mon Oct 26, 2026 11:09 AMplatelets270.0 x10^3/uL
LAB-000921Mon Oct 26, 2026 11:09 AMbilirubin0.7 mg/dL
LAB-000876Tue Oct 27, 2026 05:00 AMcreatinine1.25 mg/dL
LAB-000886Tue Oct 27, 2026 05:00 AMsodium137.0 mmol/L
LAB-000895Tue Oct 27, 2026 05:00 AMhemoglobin12.87 g/dL
LAB-000905Tue Oct 27, 2026 05:00 AMwbc8.33 x10^3/uL
LAB-000906Tue Oct 27, 2026 05:00 AMplatelets268.0 x10^3/uL
LAB-000877Wed Oct 28, 2026 05:00 AMcreatinine1.24 mg/dL
LAB-000887Wed Oct 28, 2026 05:00 AMsodium142.0 mmol/L
LAB-000896Wed Oct 28, 2026 05:00 AMhemoglobin13.1 g/dL
LAB-000907Wed Oct 28, 2026 05:00 AMwbc9.66 x10^3/uL
LAB-000908Wed Oct 28, 2026 05:00 AMplatelets200.0 x10^3/uL
LAB-000878Thu Oct 29, 2026 05:00 AMcreatinine1.25 mg/dL
LAB-000888Thu Oct 29, 2026 05:00 AMsodium136.0 mmol/L
LAB-000897Thu Oct 29, 2026 05:00 AMhemoglobin13.01 g/dL
LAB-000909Thu Oct 29, 2026 05:00 AMwbc8.83 x10^3/uL
LAB-000910Thu Oct 29, 2026 05:00 AMplatelets265.0 x10^3/uL
LAB-000879Fri Oct 30, 2026 05:00 AMcreatinine1.22 mg/dL
LAB-000889Fri Oct 30, 2026 05:00 AMsodium139.0 mmol/L
LAB-000898Fri Oct 30, 2026 05:00 AMhemoglobin12.87 g/dL
LAB-000911Fri Oct 30, 2026 05:00 AMwbc7.45 x10^3/uL
LAB-000912Fri Oct 30, 2026 05:00 AMplatelets218.0 x10^3/uL
LAB-000880Sat Oct 31, 2026 05:00 AMcreatinine1.2 mg/dL
LAB-000890Sat Oct 31, 2026 05:00 AMsodium136.0 mmol/L
LAB-000899Sat Oct 31, 2026 05:00 AMhemoglobin12.58 g/dL
LAB-000913Sat Oct 31, 2026 05:00 AMwbc6.69 x10^3/uL
LAB-000914Sat Oct 31, 2026 05:00 AMplatelets293.0 x10^3/uL
LAB-000881Sun Nov 01, 2026 05:00 AMcreatinine1.2 mg/dL
LAB-000891Sun Nov 01, 2026 05:00 AMsodium140.0 mmol/L
LAB-000900Sun Nov 01, 2026 05:00 AMhemoglobin12.93 g/dL
LAB-000915Sun Nov 01, 2026 05:00 AMwbc9.49 x10^3/uL
LAB-000916Sun Nov 01, 2026 05:00 AMplatelets275.0 x10^3/uL
LAB-000882Mon Nov 02, 2026 05:00 AMcreatinine1.26 mg/dL
LAB-000892Mon Nov 02, 2026 05:00 AMsodium140.0 mmol/L
LAB-000901Mon Nov 02, 2026 05:00 AMhemoglobin12.87 g/dL
LAB-000917Mon Nov 02, 2026 05:00 AMwbc6.97 x10^3/uL
LAB-000918Mon Nov 02, 2026 05:00 AMplatelets283.0 x10^3/uL
LAB-000883Tue Nov 03, 2026 05:00 AMcreatinine1.25 mg/dL
LAB-000893Tue Nov 03, 2026 05:00 AMsodium140.0 mmol/L
LAB-000902Tue Nov 03, 2026 05:00 AMhemoglobin12.77 g/dL
LAB-000919Tue Nov 03, 2026 05:00 AMwbc9.41 x10^3/uL
LAB-000920Tue Nov 03, 2026 05:00 AMplatelets293.0 x10^3/uL
Vitals (150)
Vitals
RowWhenKindValueDetail
VIT-002520Mon Oct 26, 2026 10:29 AMspo296.0room air
VIT-002521Mon Oct 26, 2026 10:29 AMrr16.0
VIT-002570Mon Oct 26, 2026 10:29 AMtemp_c36.6
VIT-002571Mon Oct 26, 2026 10:29 AMhr71.0
VIT-002572Mon Oct 26, 2026 10:29 AMmap78.0
VIT-002573Mon Oct 26, 2026 10:29 AMgcs15.0
VIT-002522Mon Oct 26, 2026 06:29 PMspo297.0room air
VIT-002523Mon Oct 26, 2026 06:29 PMrr18.0
VIT-002574Mon Oct 26, 2026 06:29 PMtemp_c36.7
VIT-002575Mon Oct 26, 2026 06:29 PMhr85.0
VIT-002576Mon Oct 26, 2026 06:29 PMmap85.0
VIT-002577Mon Oct 26, 2026 06:29 PMgcs15.0
VIT-002524Tue Oct 27, 2026 02:29 AMspo295.0room air
VIT-002525Tue Oct 27, 2026 02:29 AMrr19.0
VIT-002578Tue Oct 27, 2026 02:29 AMtemp_c37.5
VIT-002579Tue Oct 27, 2026 02:29 AMhr89.0
VIT-002580Tue Oct 27, 2026 02:29 AMmap91.0
VIT-002581Tue Oct 27, 2026 02:29 AMgcs15.0
VIT-002526Tue Oct 27, 2026 10:29 AMspo298.0room air
VIT-002527Tue Oct 27, 2026 10:29 AMrr20.0
VIT-002582Tue Oct 27, 2026 10:29 AMtemp_c36.6
VIT-002583Tue Oct 27, 2026 10:29 AMhr68.0
VIT-002584Tue Oct 27, 2026 10:29 AMmap83.0
VIT-002585Tue Oct 27, 2026 10:29 AMgcs15.0
VIT-002528Tue Oct 27, 2026 06:29 PMspo295.0room air
VIT-002529Tue Oct 27, 2026 06:29 PMrr17.0
VIT-002586Tue Oct 27, 2026 06:29 PMtemp_c36.7
VIT-002587Tue Oct 27, 2026 06:29 PMhr79.0
VIT-002588Tue Oct 27, 2026 06:29 PMmap91.0
VIT-002589Tue Oct 27, 2026 06:29 PMgcs15.0
VIT-002530Wed Oct 28, 2026 02:29 AMspo299.0room air
VIT-002531Wed Oct 28, 2026 02:29 AMrr19.0
VIT-002590Wed Oct 28, 2026 02:29 AMtemp_c36.8
VIT-002591Wed Oct 28, 2026 02:29 AMhr89.0
VIT-002592Wed Oct 28, 2026 02:29 AMmap87.0
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Medications, orders, echo, history (9)

Notes

History and physical · DOC-000085 · Dr. Greta Kowalczyk (resident) · Mon Oct 26, 2026 01:09 PM

Cited facts from this note (1)
infection_source
right lower lobe pneumonia · cited p. 1, line 5 · confidence 0.85
Show source for infection_source
… Hospital Medicine Attending: Dr. Cyrus Ellingham History of present illness: 63-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows right lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: heart failure with preserved ejection fraction, hypertension, hyperlipidemia, type 2 diabe …
Source document DOC-000085: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Jalen Sallow   MRN: MRN13637762   Admitted: 2026-10-26 10:09
Service: Hospital Medicine   Attending: Dr. Cyrus Ellingham

History of present illness: 63-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows right lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: heart failure with preserved ejection fraction, hypertension, hyperlipidemia, type 2 diabetes.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.
2. CKD stage 3a: renally dose medications.

Nutrition assessment · DOC-000084 · Dario Larkspur, RD (dietitian) · Tue Oct 27, 2026 02:09 PM

Cited facts from this note (8)
fat_loss
mild · cited p. 1, line 7 · confidence 0.90
Show source for fat_loss
… Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets criteria for non-severe (moderate) malnutrition.
fluid_accumulation
none · cited p. 1, line 7 · confidence 0.90
Show source for fluid_accumulation
… ake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets criteria for non-severe (moderate) malnutrition.
intake_days
11 · cited p. 1, line 5 · confidence 0.95
Show source for intake_days
NUTRITION ASSESSMENT (Registered Dietitian) Patient: Jalen Sallow MRN: MRN13637762 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip …
intake_pct
60 · cited p. 1, line 5 · confidence 0.95
Show source for intake_pct
NUTRITION ASSESSMENT (Registered Dietitian) Patient: Jalen Sallow MRN: MRN13637762 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip …
muscle_loss
mild · cited p. 1, line 7 · confidence 0.90
Show source for muscle_loss
… estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets criteria for non-severe (moderate) malnutrition.
nutrition_context
acute · cited p. 1, line 4 · confidence 0.95
Show source for nutrition_context
NUTRITION ASSESSMENT (Registered Dietitian) Patient: Jalen Sallow MRN: MRN13637762 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneo …
weight_loss_days
30 · cited p. 1, line 6 · confidence 0.95
Show source for weight_loss_days
… egistered Dietitian) Patient: Jalen Sallow MRN: MRN13637762 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets cri …
weight_loss_pct
3 · cited p. 1, line 6 · confidence 0.95
Show source for weight_loss_pct
… egistered Dietitian) Patient: Jalen Sallow MRN: MRN13637762 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets cri …
Source document DOC-000084: Nutrition assessment (synthetic)
NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Jalen Sallow   MRN: MRN13637762

Context: acute illness
Intake: estimated energy intake 60% of needs for 11 days.
Weight history: 3% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Grip strength: not assessed.
Assessment: meets criteria for non-severe (moderate) malnutrition.

Progress note · DOC-000086 · Dr. Greta Kowalczyk (resident) · Wed Oct 28, 2026 01:09 PM

Source document DOC-000086: Progress note (synthetic)
PROGRESS NOTE (Resident)
Patient: Jalen Sallow   MRN: MRN13637762   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.
2. Severe protein-calorie malnutrition: dietitian following, supplements.
3. CHF: diuresis and daily weights; monitor electrolytes.

Resident: Dr. Greta Kowalczyk   Attending cosign: completed

Discharge summary · DOC-000087 · Dr. Cyrus Ellingham (attending) · Tue Nov 03, 2026 04:03 PM

Source document DOC-000087: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Jalen Sallow   MRN: MRN13637762
Admitted 2026-10-26; discharged 2026-11-03.

Discharge diagnoses:
- community-acquired pneumonia
- severe protein-calorie malnutrition
- CKD stage 3a
- CHF
- hypertension
- hyperlipidemia
- type 2 diabetes

Disposition: home with follow-up.