Skip to main content
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.

← All encounters

ENC-00028: Greta Nakashima

62M · MRN13453217 · Hospital Medicine · admitted Mon Nov 02, 2026 04:51 PM · discharged Mon Nov 09, 2026 03:10 PM · attending Dr. Rosalind Quillan · resident Dr. Keira Upfield · 162 cm, 57.3 kg

Documented diagnoses (current)

  • Principal: “sepsis” · A41.9 Sepsis, unspecified organism
  • “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
  • “severe protein-calorie malnutrition” · E43 Unspecified severe protein-calorie malnutrition
  • “AKI” · N17.9 Acute kidney failure, unspecified
  • “type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications

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 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 Clinical validation gap Documented “AKI” (N17.9) but the criteria are not met: KDIGO creatinine and urine-output criteria not met.
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=1.046, t.ratio_s1=1.5, creat_rise_48h=0.09, 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=1.046, t.ratio_s3=3.0, creat_peak=1.59, 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=1.046, 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=0.09, 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=M, hgb_nadir=13.35, 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=0.4, 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=0.4, t.drop_min=1.0, prbc_units=0 false
outcome: not_anaemic present(hgb_nadir) and not anaemic hgb_nadir=13.35, anaemic=False true
Chronic kidney disease Criteria met Specificity gap Criteria support Chronic kidney disease stage 3a (N18.31); no corresponding diagnosis is documented.
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=317, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=49.2, egfr_late=51.5 51.5
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=49.2, t.g2=60, egfr_late=51.5 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=51.5, 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=49.2, egfr_late=51.5, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=51.5, t.g2=60 false
outcome: g3a category == 'G3a' category=G3a 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 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=9.0, 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=9.0, 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=9.0, 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=9.0, 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=62, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=21.8, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=21.8, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=21.8, t.c1=30 false
outcome: not_met bmi < t.c1 bmi=21.8, 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 Clinical validation gap Documented “sepsis” (A41.9) but the criteria are not met: Neither definition met: 0 SIRS criteria, SOFA change 0.
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=37.7, t.t_hi=38, temp_min_48h=37.2, t.t_lo=36 false
derived: sirs_hr coalesce(hr_max_48h > t.hr, false) hr_max_48h=86.0, 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=9.07, t.wbc_hi=12, wbc_min_48h=7.66, 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=0.8 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=79.0 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=1.59 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=1.52 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 (43)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-000950Thu Oct 23, 2025 09:15 AMcreatinine1.58 mg/dL
LAB-000951Sat Sep 05, 2026 10:05 AMcreatinine1.52 mg/dL
LAB-000952Mon Nov 02, 2026 05:51 PMcreatinine1.5 mg/dL
LAB-000960Mon Nov 02, 2026 05:51 PMsodium137.0 mmol/L
LAB-000968Mon Nov 02, 2026 05:51 PMhemoglobin13.78 g/dL
LAB-000976Mon Nov 02, 2026 05:51 PMwbc7.66 x10^3/uL
LAB-000977Mon Nov 02, 2026 05:51 PMplatelets200.0 x10^3/uL
LAB-000992Mon Nov 02, 2026 05:51 PMbilirubin0.8 mg/dL
LAB-000953Tue Nov 03, 2026 05:00 AMcreatinine1.59 mg/dL
LAB-000961Tue Nov 03, 2026 05:00 AMsodium141.0 mmol/L
LAB-000969Tue Nov 03, 2026 05:00 AMhemoglobin13.37 g/dL
LAB-000978Tue Nov 03, 2026 05:00 AMwbc9.07 x10^3/uL
LAB-000979Tue Nov 03, 2026 05:00 AMplatelets206.0 x10^3/uL
LAB-000954Wed Nov 04, 2026 05:00 AMcreatinine1.54 mg/dL
LAB-000962Wed Nov 04, 2026 05:00 AMsodium139.0 mmol/L
LAB-000970Wed Nov 04, 2026 05:00 AMhemoglobin13.35 g/dL
LAB-000980Wed Nov 04, 2026 05:00 AMwbc7.84 x10^3/uL
LAB-000981Wed Nov 04, 2026 05:00 AMplatelets248.0 x10^3/uL
LAB-000955Thu Nov 05, 2026 05:00 AMcreatinine1.5 mg/dL
LAB-000963Thu Nov 05, 2026 05:00 AMsodium138.0 mmol/L
LAB-000971Thu Nov 05, 2026 05:00 AMhemoglobin13.7 g/dL
LAB-000982Thu Nov 05, 2026 05:00 AMwbc8.32 x10^3/uL
LAB-000983Thu Nov 05, 2026 05:00 AMplatelets238.0 x10^3/uL
LAB-000956Fri Nov 06, 2026 05:00 AMcreatinine1.58 mg/dL
LAB-000964Fri Nov 06, 2026 05:00 AMsodium136.0 mmol/L
LAB-000972Fri Nov 06, 2026 05:00 AMhemoglobin13.75 g/dL
LAB-000984Fri Nov 06, 2026 05:00 AMwbc9.22 x10^3/uL
LAB-000985Fri Nov 06, 2026 05:00 AMplatelets287.0 x10^3/uL
LAB-000957Sat Nov 07, 2026 05:00 AMcreatinine1.58 mg/dL
LAB-000965Sat Nov 07, 2026 05:00 AMsodium139.0 mmol/L
LAB-000973Sat Nov 07, 2026 05:00 AMhemoglobin13.38 g/dL
LAB-000986Sat Nov 07, 2026 05:00 AMwbc9.22 x10^3/uL
LAB-000987Sat Nov 07, 2026 05:00 AMplatelets241.0 x10^3/uL
LAB-000958Sun Nov 08, 2026 05:00 AMcreatinine1.57 mg/dL
LAB-000966Sun Nov 08, 2026 05:00 AMsodium140.0 mmol/L
LAB-000974Sun Nov 08, 2026 05:00 AMhemoglobin13.69 g/dL
LAB-000988Sun Nov 08, 2026 05:00 AMwbc9.94 x10^3/uL
LAB-000989Sun Nov 08, 2026 05:00 AMplatelets200.0 x10^3/uL
LAB-000959Mon Nov 09, 2026 05:00 AMcreatinine1.57 mg/dL
LAB-000967Mon Nov 09, 2026 05:00 AMsodium137.0 mmol/L
LAB-000975Mon Nov 09, 2026 05:00 AMhemoglobin13.73 g/dL
LAB-000990Mon Nov 09, 2026 05:00 AMwbc6.72 x10^3/uL
LAB-000991Mon Nov 09, 2026 05:00 AMplatelets287.0 x10^3/uL
Vitals (126)
Vitals
RowWhenKindValueDetail
VIT-002742Mon Nov 02, 2026 05:11 PMspo296.0room air
VIT-002743Mon Nov 02, 2026 05:11 PMrr18.0
VIT-002784Mon Nov 02, 2026 05:11 PMtemp_c37.6
VIT-002785Mon Nov 02, 2026 05:11 PMhr85.0
VIT-002786Mon Nov 02, 2026 05:11 PMmap81.0
VIT-002787Mon Nov 02, 2026 05:11 PMgcs15.0
VIT-002744Tue Nov 03, 2026 01:11 AMspo296.0room air
VIT-002745Tue Nov 03, 2026 01:11 AMrr17.0
VIT-002788Tue Nov 03, 2026 01:11 AMtemp_c37.6
VIT-002789Tue Nov 03, 2026 01:11 AMhr72.0
VIT-002790Tue Nov 03, 2026 01:11 AMmap80.0
VIT-002791Tue Nov 03, 2026 01:11 AMgcs15.0
VIT-002746Tue Nov 03, 2026 09:11 AMspo297.0room air
VIT-002747Tue Nov 03, 2026 09:11 AMrr20.0
VIT-002792Tue Nov 03, 2026 09:11 AMtemp_c37.5
VIT-002793Tue Nov 03, 2026 09:11 AMhr72.0
VIT-002794Tue Nov 03, 2026 09:11 AMmap92.0
VIT-002795Tue Nov 03, 2026 09:11 AMgcs15.0
VIT-002748Tue Nov 03, 2026 05:11 PMspo294.0room air
VIT-002749Tue Nov 03, 2026 05:11 PMrr20.0
VIT-002796Tue Nov 03, 2026 05:11 PMtemp_c37.6
VIT-002797Tue Nov 03, 2026 05:11 PMhr86.0
VIT-002798Tue Nov 03, 2026 05:11 PMmap79.0
VIT-002799Tue Nov 03, 2026 05:11 PMgcs15.0
VIT-002750Wed Nov 04, 2026 01:11 AMspo296.0room air
VIT-002751Wed Nov 04, 2026 01:11 AMrr18.0
VIT-002800Wed Nov 04, 2026 01:11 AMtemp_c37.2
VIT-002801Wed Nov 04, 2026 01:11 AMhr78.0
VIT-002802Wed Nov 04, 2026 01:11 AMmap88.0
VIT-002803Wed Nov 04, 2026 01:11 AMgcs15.0
VIT-002752Wed Nov 04, 2026 09:11 AMspo295.0room air
VIT-002753Wed Nov 04, 2026 09:11 AMrr15.0
VIT-002804Wed Nov 04, 2026 09:11 AMtemp_c37.7
VIT-002805Wed Nov 04, 2026 09:11 AMhr75.0
VIT-002806Wed Nov 04, 2026 09:11 AMmap86.0
VIT-002807Wed Nov 04, 2026 09:11 AMgcs15.0
VIT-002754Wed Nov 04, 2026 05:11 PMspo295.0room air
VIT-002755Wed Nov 04, 2026 05:11 PMrr20.0
VIT-002808Wed Nov 04, 2026 05:11 PMtemp_c37.3
VIT-002809Wed Nov 04, 2026 05:11 PMhr78.0
VIT-002810Wed Nov 04, 2026 05:11 PMmap77.0
VIT-002811Wed Nov 04, 2026 05:11 PMgcs15.0
VIT-002756Thu Nov 05, 2026 01:11 AMspo299.0room air
VIT-002757Thu Nov 05, 2026 01:11 AMrr16.0
VIT-002812Thu Nov 05, 2026 01:11 AMtemp_c36.8
VIT-002813Thu Nov 05, 2026 01:11 AMhr74.0
VIT-002814Thu Nov 05, 2026 01:11 AMmap92.0
VIT-002815Thu Nov 05, 2026 01:11 AMgcs15.0
VIT-002758Thu Nov 05, 2026 09:11 AMspo294.0room air
VIT-002759Thu Nov 05, 2026 09:11 AMrr15.0
VIT-002816Thu Nov 05, 2026 09:11 AMtemp_c36.9
VIT-002817Thu Nov 05, 2026 09:11 AMhr79.0
VIT-002818Thu Nov 05, 2026 09:11 AMmap82.0
VIT-002819Thu Nov 05, 2026 09:11 AMgcs15.0
VIT-002760Thu Nov 05, 2026 05:11 PMspo294.0room air
VIT-002761Thu Nov 05, 2026 05:11 PMrr15.0
VIT-002820Thu Nov 05, 2026 05:11 PMtemp_c37.6
VIT-002821Thu Nov 05, 2026 05:11 PMhr83.0
VIT-002822Thu Nov 05, 2026 05:11 PMmap84.0
VIT-002823Thu Nov 05, 2026 05:11 PMgcs15.0
VIT-002762Fri Nov 06, 2026 01:11 AMspo297.0room air
VIT-002763Fri Nov 06, 2026 01:11 AMrr15.0
VIT-002824Fri Nov 06, 2026 01:11 AMtemp_c37.2
VIT-002825Fri Nov 06, 2026 01:11 AMhr83.0
VIT-002826Fri Nov 06, 2026 01:11 AMmap83.0
VIT-002827Fri Nov 06, 2026 01:11 AMgcs15.0
VIT-002764Fri Nov 06, 2026 09:11 AMspo297.0room air
VIT-002765Fri Nov 06, 2026 09:11 AMrr15.0
VIT-002828Fri Nov 06, 2026 09:11 AMtemp_c36.9
VIT-002829Fri Nov 06, 2026 09:11 AMhr80.0
VIT-002830Fri Nov 06, 2026 09:11 AMmap77.0
VIT-002831Fri Nov 06, 2026 09:11 AMgcs15.0
VIT-002766Fri Nov 06, 2026 05:11 PMspo296.0room air
VIT-002767Fri Nov 06, 2026 05:11 PMrr20.0
VIT-002832Fri Nov 06, 2026 05:11 PMtemp_c36.8
VIT-002833Fri Nov 06, 2026 05:11 PMhr86.0
VIT-002834Fri Nov 06, 2026 05:11 PMmap90.0
VIT-002835Fri Nov 06, 2026 05:11 PMgcs15.0
VIT-002768Sat Nov 07, 2026 01:11 AMspo296.0room air
VIT-002769Sat Nov 07, 2026 01:11 AMrr20.0
VIT-002836Sat Nov 07, 2026 01:11 AMtemp_c36.7
VIT-002837Sat Nov 07, 2026 01:11 AMhr76.0
VIT-002838Sat Nov 07, 2026 01:11 AMmap81.0
VIT-002839Sat Nov 07, 2026 01:11 AMgcs15.0
VIT-002770Sat Nov 07, 2026 09:11 AMspo294.0room air
VIT-002771Sat Nov 07, 2026 09:11 AMrr17.0
VIT-002840Sat Nov 07, 2026 09:11 AMtemp_c37.3
VIT-002841Sat Nov 07, 2026 09:11 AMhr80.0
VIT-002842Sat Nov 07, 2026 09:11 AMmap74.0
VIT-002843Sat Nov 07, 2026 09:11 AMgcs15.0
VIT-002772Sat Nov 07, 2026 05:11 PMspo296.0room air
VIT-002773Sat Nov 07, 2026 05:11 PMrr17.0
VIT-002844Sat Nov 07, 2026 05:11 PMtemp_c36.8
VIT-002845Sat Nov 07, 2026 05:11 PMhr77.0
VIT-002846Sat Nov 07, 2026 05:11 PMmap80.0
VIT-002847Sat Nov 07, 2026 05:11 PMgcs15.0
VIT-002774Sun Nov 08, 2026 01:11 AMspo299.0room air
VIT-002775Sun Nov 08, 2026 01:11 AMrr18.0
VIT-002848Sun Nov 08, 2026 01:11 AMtemp_c37.0
VIT-002849Sun Nov 08, 2026 01:11 AMhr74.0
VIT-002850Sun Nov 08, 2026 01:11 AMmap79.0
VIT-002851Sun Nov 08, 2026 01:11 AMgcs15.0
VIT-002776Sun Nov 08, 2026 09:11 AMspo297.0room air
VIT-002777Sun Nov 08, 2026 09:11 AMrr17.0
VIT-002852Sun Nov 08, 2026 09:11 AMtemp_c36.7
VIT-002853Sun Nov 08, 2026 09:11 AMhr72.0
VIT-002854Sun Nov 08, 2026 09:11 AMmap76.0
VIT-002855Sun Nov 08, 2026 09:11 AMgcs15.0
VIT-002778Sun Nov 08, 2026 05:11 PMspo295.0room air
VIT-002779Sun Nov 08, 2026 05:11 PMrr18.0
VIT-002856Sun Nov 08, 2026 05:11 PMtemp_c37.4
VIT-002857Sun Nov 08, 2026 05:11 PMhr78.0
VIT-002858Sun Nov 08, 2026 05:11 PMmap75.0
VIT-002859Sun Nov 08, 2026 05:11 PMgcs15.0
VIT-002780Mon Nov 09, 2026 01:11 AMspo295.0room air
VIT-002781Mon Nov 09, 2026 01:11 AMrr15.0
VIT-002860Mon Nov 09, 2026 01:11 AMtemp_c36.7
VIT-002861Mon Nov 09, 2026 01:11 AMhr86.0
VIT-002862Mon Nov 09, 2026 01:11 AMmap85.0
VIT-002863Mon Nov 09, 2026 01:11 AMgcs15.0
VIT-002782Mon Nov 09, 2026 09:11 AMspo299.0room air
VIT-002783Mon Nov 09, 2026 09:11 AMrr15.0
VIT-002864Mon Nov 09, 2026 09:11 AMtemp_c37.2
VIT-002865Mon Nov 09, 2026 09:11 AMhr73.0
VIT-002866Mon Nov 09, 2026 09:11 AMmap80.0
VIT-002867Mon Nov 09, 2026 09:11 AMgcs15.0
Medications, orders, echo, history (4)

Notes

History and physical · DOC-000093 · Dr. Keira Upfield (resident) · Mon Nov 02, 2026 07:51 PM

Cited facts from this note (1)
infection_source
multifocal pneumonia · cited p. 1, line 5 · confidence 0.85
Show source for infection_source
… 6-11-02 16:51 Service: Hospital Medicine Attending: Dr. Rosalind Quillan History of present illness: 62-year-old man admitted with sepsis. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: type 2 diabetes. Review of systems otherwise negative. Exam: Lungs: clear to auscultation …
Source document DOC-000093: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Greta Nakashima   MRN: MRN13453217   Admitted: 2026-11-02 16:51
Service: Hospital Medicine   Attending: Dr. Rosalind Quillan

History of present illness: 62-year-old man admitted with sepsis. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: type 2 diabetes.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Sepsis: antibiotics, fluids.
2. Community-acquired pneumonia: antibiotics.

Nutrition assessment · DOC-000092 · Vera Pemberton, RD (dietitian) · Tue Nov 03, 2026 07:51 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 9 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
… take 60% of needs for 9 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
9 · cited p. 1, line 5 · confidence 0.95
Show source for intake_days
NUTRITION ASSESSMENT (Registered Dietitian) Patient: Greta Nakashima MRN: MRN13453217 Context: acute illness Intake: estimated energy intake 60% of needs for 9 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: Greta Nakashima MRN: MRN13453217 Context: acute illness Intake: estimated energy intake 60% of needs for 9 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 9 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: Greta Nakashima MRN: MRN13453217 Context: acute illness Intake: estimated energy intake 60% of needs for 9 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneou …
weight_loss_days
30 · cited p. 1, line 6 · confidence 0.95
Show source for weight_loss_days
… istered Dietitian) Patient: Greta Nakashima MRN: MRN13453217 Context: acute illness Intake: estimated energy intake 60% of needs for 9 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
… istered Dietitian) Patient: Greta Nakashima MRN: MRN13453217 Context: acute illness Intake: estimated energy intake 60% of needs for 9 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-000092: Nutrition assessment (synthetic)
NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Greta Nakashima   MRN: MRN13453217

Context: acute illness
Intake: estimated energy intake 60% of needs for 9 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-000094 · Dr. Keira Upfield (resident) · Wed Nov 04, 2026 05:51 PM

Source document DOC-000094: Progress note (synthetic)
PROGRESS NOTE (Resident)
Patient: Greta Nakashima   MRN: MRN13453217   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.
2. Severe protein-calorie malnutrition: dietitian following, supplements.
3. AKI: trend creatinine, hold nephrotoxins, strict intake and output.

Resident: Dr. Keira Upfield   Attending cosign: completed

Discharge summary · DOC-000095 · Dr. Rosalind Quillan (attending) · Mon Nov 09, 2026 03:10 PM

Source document DOC-000095: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Greta Nakashima   MRN: MRN13453217
Admitted 2026-11-02; discharged 2026-11-09.

Discharge diagnoses:
- sepsis
- community-acquired pneumonia
- severe protein-calorie malnutrition
- AKI
- type 2 diabetes

Disposition: home with follow-up.