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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-00031: Gideon Ashgrove

62F · MRN82452791 · Hospital Medicine · admitted Wed Nov 04, 2026 12:34 PM · discharged Wed Nov 11, 2026 03:47 PM · attending Dr. Rosalind Quillan · resident Dr. Noor Halvorsen · 164 cm, 105.9 kg

Documented diagnoses (current)

  • Principal: “upper GI bleed” · K92.2 Gastrointestinal hemorrhage, unspecified
  • “obesity” · E66.9 Obesity, unspecified
  • “CKD stage 3a” · N18.31 Chronic kidney disease, stage 3a
  • “acute blood loss anemia” · D62 Acute posthemorrhagic anemia
  • “type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications
  • “GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis

Illustrative grouping now: MS-DRG 378 GI hemorrhage with CC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 379.

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=1.05, t.ratio_s1=1.5, creat_rise_48h=0.08, 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=1.05, 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=1.05, 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=0.08, t.rise_abs=0.3, rrt_started=False true
outcome: aki_staged stage >= 1 and baseline_independent stage=0, baseline_independent=True false
outcome: aki_presumed_baseline stage >= 1 stage=0 false
outcome: not_met stage == 0 stage=0 true
Acute blood loss anaemia Criteria met Clinical validation gap Documented “acute blood loss anemia” (D62) is more specific than the criteria support (Anemia (acute blood-loss criteria not met), D64.9).
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=10.45, t.hb_m=13, t.hb_f=12 true
derived: acute_fall hgb_drop >= t.drop_major or prbc_units >= t.prbc_major hgb_drop=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=True, anaemic=True, acute_fall=False false
outcome: anaemia_only anaemic and hgb_drop < t.drop_min and prbc_units == 0 anaemic=True, hgb_drop=0.4, t.drop_min=1.0, prbc_units=0 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=200, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=53.9, egfr_late=51.2 53.9
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=53.9, t.g2=60, egfr_late=51.2 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=53.9, 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=53.9, egfr_late=51.2, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=53.9, 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 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 met Specificity gap Documented “obesity” (E66.9); criteria support the more specific Obesity, class 2 (E66.812).
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=39.4, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=39.4, t.c2=35 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=95.0, 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=95.0, 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=36.5, t.t_lo=36 false
derived: sirs_hr coalesce(hr_max_48h > t.hr, false) hr_max_48h=88.0, 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=7.34, t.wbc_hi=12, wbc_min_48h=6.36, 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=188.0 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=0.88 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=77.0 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=1.2 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=False, sofa_delta=0, t.sofa_delta=2 false
derived: sepsis2 infection_documented and sirs_count >= t.sirs_min infection_documented=False, sirs_count=0, t.sirs_min=2 false
derived: shock sepsis3 and norepi_max_48h > 0 and coalesce(lactate_max_48h > t.lactate, false) sepsis3=False, norepi_max_48h=0.0, lactate_max_48h=unknown, t.lactate=2 false
outcome: no_infection not infection_documented infection_documented=False true

Structured data

Labs (43)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-001040Tue Dec 30, 2025 09:15 AMcreatinine1.15 mg/dL
LAB-001041Sun Jul 19, 2026 10:05 AMcreatinine1.2 mg/dL
LAB-001042Wed Nov 04, 2026 01:34 PMcreatinine1.25 mg/dL
LAB-001050Wed Nov 04, 2026 01:34 PMsodium138.0 mmol/L
LAB-001058Wed Nov 04, 2026 01:34 PMhemoglobin10.85 g/dL
LAB-001066Wed Nov 04, 2026 01:34 PMwbc6.36 x10^3/uL
LAB-001067Wed Nov 04, 2026 01:34 PMplatelets193.0 x10^3/uL
LAB-001082Wed Nov 04, 2026 01:34 PMbilirubin0.88 mg/dL
LAB-001043Thu Nov 05, 2026 05:00 AMcreatinine1.18 mg/dL
LAB-001051Thu Nov 05, 2026 05:00 AMsodium138.0 mmol/L
LAB-001059Thu Nov 05, 2026 05:00 AMhemoglobin10.45 g/dL
LAB-001068Thu Nov 05, 2026 05:00 AMwbc7.17 x10^3/uL
LAB-001069Thu Nov 05, 2026 05:00 AMplatelets188.0 x10^3/uL
LAB-001044Fri Nov 06, 2026 05:00 AMcreatinine1.23 mg/dL
LAB-001052Fri Nov 06, 2026 05:00 AMsodium137.0 mmol/L
LAB-001060Fri Nov 06, 2026 05:00 AMhemoglobin10.85 g/dL
LAB-001070Fri Nov 06, 2026 05:00 AMwbc7.34 x10^3/uL
LAB-001071Fri Nov 06, 2026 05:00 AMplatelets188.0 x10^3/uL
LAB-001045Sat Nov 07, 2026 05:00 AMcreatinine1.26 mg/dL
LAB-001053Sat Nov 07, 2026 05:00 AMsodium142.0 mmol/L
LAB-001061Sat Nov 07, 2026 05:00 AMhemoglobin10.45 g/dL
LAB-001072Sat Nov 07, 2026 05:00 AMwbc6.99 x10^3/uL
LAB-001073Sat Nov 07, 2026 05:00 AMplatelets254.0 x10^3/uL
LAB-001046Sun Nov 08, 2026 05:00 AMcreatinine1.22 mg/dL
LAB-001054Sun Nov 08, 2026 05:00 AMsodium138.0 mmol/L
LAB-001062Sun Nov 08, 2026 05:00 AMhemoglobin10.85 g/dL
LAB-001074Sun Nov 08, 2026 05:00 AMwbc7.43 x10^3/uL
LAB-001075Sun Nov 08, 2026 05:00 AMplatelets251.0 x10^3/uL
LAB-001047Mon Nov 09, 2026 05:00 AMcreatinine1.2 mg/dL
LAB-001055Mon Nov 09, 2026 05:00 AMsodium140.0 mmol/L
LAB-001063Mon Nov 09, 2026 05:00 AMhemoglobin10.45 g/dL
LAB-001076Mon Nov 09, 2026 05:00 AMwbc8.71 x10^3/uL
LAB-001077Mon Nov 09, 2026 05:00 AMplatelets165.0 x10^3/uL
LAB-001048Tue Nov 10, 2026 05:00 AMcreatinine1.19 mg/dL
LAB-001056Tue Nov 10, 2026 05:00 AMsodium137.0 mmol/L
LAB-001064Tue Nov 10, 2026 05:00 AMhemoglobin10.85 g/dL
LAB-001078Tue Nov 10, 2026 05:00 AMwbc5.69 x10^3/uL
LAB-001079Tue Nov 10, 2026 05:00 AMplatelets192.0 x10^3/uL
LAB-001049Wed Nov 11, 2026 05:00 AMcreatinine1.24 mg/dL
LAB-001057Wed Nov 11, 2026 05:00 AMsodium136.0 mmol/L
LAB-001065Wed Nov 11, 2026 05:00 AMhemoglobin10.45 g/dL
LAB-001080Wed Nov 11, 2026 05:00 AMwbc9.37 x10^3/uL
LAB-001081Wed Nov 11, 2026 05:00 AMplatelets299.0 x10^3/uL
Vitals (132)
Vitals
RowWhenKindValueDetail
VIT-002984Wed Nov 04, 2026 12:54 PMspo299.0room air
VIT-002985Wed Nov 04, 2026 12:54 PMrr14.0
VIT-003028Wed Nov 04, 2026 12:54 PMtemp_c37.3
VIT-003029Wed Nov 04, 2026 12:54 PMhr72.0
VIT-003030Wed Nov 04, 2026 12:54 PMmap80.0
VIT-003031Wed Nov 04, 2026 12:54 PMgcs15.0
VIT-002986Wed Nov 04, 2026 08:54 PMspo297.0room air
VIT-002987Wed Nov 04, 2026 08:54 PMrr19.0
VIT-003032Wed Nov 04, 2026 08:54 PMtemp_c36.6
VIT-003033Wed Nov 04, 2026 08:54 PMhr86.0
VIT-003034Wed Nov 04, 2026 08:54 PMmap90.0
VIT-003035Wed Nov 04, 2026 08:54 PMgcs15.0
VIT-002988Thu Nov 05, 2026 04:54 AMspo298.0room air
VIT-002989Thu Nov 05, 2026 04:54 AMrr18.0
VIT-003036Thu Nov 05, 2026 04:54 AMtemp_c37.5
VIT-003037Thu Nov 05, 2026 04:54 AMhr80.0
VIT-003038Thu Nov 05, 2026 04:54 AMmap85.0
VIT-003039Thu Nov 05, 2026 04:54 AMgcs15.0
VIT-002990Thu Nov 05, 2026 12:54 PMspo299.0room air
VIT-002991Thu Nov 05, 2026 12:54 PMrr17.0
VIT-003040Thu Nov 05, 2026 12:54 PMtemp_c37.5
VIT-003041Thu Nov 05, 2026 12:54 PMhr83.0
VIT-003042Thu Nov 05, 2026 12:54 PMmap82.0
VIT-003043Thu Nov 05, 2026 12:54 PMgcs15.0
VIT-002992Thu Nov 05, 2026 08:54 PMspo297.0room air
VIT-002993Thu Nov 05, 2026 08:54 PMrr20.0
VIT-003044Thu Nov 05, 2026 08:54 PMtemp_c36.5
VIT-003045Thu Nov 05, 2026 08:54 PMhr88.0
VIT-003046Thu Nov 05, 2026 08:54 PMmap79.0
VIT-003047Thu Nov 05, 2026 08:54 PMgcs15.0
VIT-002994Fri Nov 06, 2026 04:54 AMspo298.0room air
VIT-002995Fri Nov 06, 2026 04:54 AMrr20.0
VIT-003048Fri Nov 06, 2026 04:54 AMtemp_c36.8
VIT-003049Fri Nov 06, 2026 04:54 AMhr73.0
VIT-003050Fri Nov 06, 2026 04:54 AMmap77.0
VIT-003051Fri Nov 06, 2026 04:54 AMgcs15.0
VIT-002996Fri Nov 06, 2026 12:54 PMspo297.0room air
VIT-002997Fri Nov 06, 2026 12:54 PMrr18.0
VIT-003052Fri Nov 06, 2026 12:54 PMtemp_c36.6
VIT-003053Fri Nov 06, 2026 12:54 PMhr70.0
VIT-003054Fri Nov 06, 2026 12:54 PMmap80.0
VIT-003055Fri Nov 06, 2026 12:54 PMgcs15.0
VIT-002998Fri Nov 06, 2026 08:54 PMspo296.0room air
VIT-002999Fri Nov 06, 2026 08:54 PMrr14.0
VIT-003056Fri Nov 06, 2026 08:54 PMtemp_c36.5
VIT-003057Fri Nov 06, 2026 08:54 PMhr78.0
VIT-003058Fri Nov 06, 2026 08:54 PMmap92.0
VIT-003059Fri Nov 06, 2026 08:54 PMgcs15.0
VIT-003000Sat Nov 07, 2026 04:54 AMspo296.0room air
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Medications, orders, echo, history (0)

Notes

History and physical · DOC-000104 · Dr. Noor Halvorsen (resident) · Wed Nov 04, 2026 03:34 PM

Cited facts from this note (1)
bleeding_source
hematemesis · cited p. 1, line 5 · confidence 0.85
Show source for bleeding_source
… e: Hospital Medicine Attending: Dr. Rosalind Quillan History of present illness: 62-year-old woman admitted with upper GI bleed. Presented after two days of hematemesis; GI consulted for endoscopy. Past medical history: type 2 diabetes, GERD. Review of systems otherwise negative. Exam: Lungs: scattered crackles at the bases, n …
Source document DOC-000104: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Gideon Ashgrove   MRN: MRN82452791   Admitted: 2026-11-04 12:34
Service: Hospital Medicine   Attending: Dr. Rosalind Quillan

History of present illness: 62-year-old woman admitted with upper GI bleed. Presented after two days of hematemesis; GI consulted for endoscopy.
Past medical history: type 2 diabetes, GERD.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Upper GI bleed: PPI, GI following.
2. CKD stage 3a: renally dose medications.

Nutrition assessment · DOC-000103 · Viggo Ravensworth, RD (dietitian) · Thu Nov 05, 2026 02:34 PM

Cited facts from this note (5)
fat_loss
none · cited p. 1, line 7 · confidence 0.90
Show source for fat_loss
… MRN: MRN82452791 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: Gideon Ashgrove MRN: MRN82452791 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: Gideon Ashgrove MRN: MRN82452791 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-000103: Nutrition assessment (synthetic)
NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Gideon Ashgrove   MRN: MRN82452791

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-000105 · Dr. Noor Halvorsen (resident) · Fri Nov 06, 2026 03:34 PM

Source document DOC-000105: Progress note (synthetic)
PROGRESS NOTE (Resident)
Patient: Gideon Ashgrove   MRN: MRN82452791   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Upper GI bleed: continue current management.
2. Obesity: counsel on weight.
3. Acute blood loss anemia: trend hemoglobin, transfuse if needed.

Resident: Dr. Noor Halvorsen   Attending cosign: completed

Discharge summary · DOC-000106 · Dr. Rosalind Quillan (attending) · Wed Nov 11, 2026 03:47 PM

Source document DOC-000106: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Gideon Ashgrove   MRN: MRN82452791
Admitted 2026-11-04; discharged 2026-11-11.

Discharge diagnoses:
- upper GI bleed
- obesity
- CKD stage 3a
- acute blood loss anemia
- type 2 diabetes
- GERD

Disposition: home with follow-up.