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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-00038: Wes Stavros

73F · MRN57794122 · Pulmonology · admitted Thu Oct 29, 2026 04:47 PM · discharged Fri Nov 06, 2026 03:40 PM · attending Dr. Gideon Zeller · 164 cm, 103.5 kg

Documented diagnoses (current)

  • Principal: “COPD exacerbation” · J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
  • “obesity” · E66.9 Obesity, unspecified
  • “acute kidney injury” · N17.9 Acute kidney failure, unspecified
  • “HFrEF” · I50.20 Unspecified systolic (congestive) heart failure

Illustrative grouping now: MS-DRG 191 Chronic obstructive pulmonary disease with CC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 190.

Queries and events

No queries yet.

All rules applied

Every rule's outcome for this encounter (clean results included)
RuleCriteriaFindingOutcome
Acute kidney injury Criteria met No gap Supported as documented (N17.9).
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=3.277, t.ratio_s1=1.5, creat_rise_48h=0.6, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, t.uo_s1_h=6 true
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=True, creat_ratio=3.277, t.ratio_s3=3.0, creat_peak=2.72, 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 true
derived: stage2 creat_ratio >= t.ratio_s2 or coalesce(uo_hours_lt_0_5 >= t.uo_s2_h, false) creat_ratio=3.277, t.ratio_s2=2.0, uo_hours_lt_0_5=unknown, t.uo_s2_h=12 true
derived: stage case(stage3, 3, stage2, 2, meets_definition, 1, 0) stage3=True, stage2=True, meets_definition=True 3
derived: baseline_independent creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started creat_baseline_known=True, creat_rise_48h=0.6, t.rise_abs=0.3, rrt_started=False true
outcome: aki_staged stage >= 1 and baseline_independent stage=3, baseline_independent=True 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=13.55, 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=13.55, 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=348, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=77.8, egfr_late=74.4 77.8
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=77.8, t.g2=60, egfr_late=74.4 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=77.8, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15 G1-G2
outcome: duration_not_shown not chronic chronic=True false
outcome: straddles_60 not both_below_60 and min(egfr_early, egfr_late) < t.g2 both_below_60=False, egfr_early=77.8, egfr_late=74.4, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=77.8, t.g2=60 true
Heart failure Criteria met Specificity gap Documented “HFrEF” (I50.20); criteria support the more specific Acute on chronic systolic (HFrEF) heart failure (I50.23).
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=1060.0, t.bnp=100, ntprobnp_max=unknown, t.ntprobnp=300 true
derived: acute_count count(iv_loop_diuretic, np_elevated, new_o2) iv_loop_diuretic=True, np_elevated=True, new_o2=False 2
derived: hf_type case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange') lvef=21.0, t.ref=40, t.pres=50 systolic
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=21.0, 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=2, hf_history=True acute on chronic
outcome: improved_ef improved improved=False false
outcome: midrange hf_type == 'midrange' hf_type=systolic false
outcome: sys_aoc hf_type == 'systolic' and acuity == 'acute on chronic' hf_type=systolic, acuity=acute on 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 Insufficient data No gap Insufficient data: the criteria could not be applied.
Trace
Rule trace (rule malnutrition v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
StepExpressionInputs and thresholds readResult
derived: a_sev_intake intake_pct <= t.a_sev_intake_pct and intake_days >= t.a_sev_intake_days intake_pct=unknown, t.a_sev_intake_pct=50, intake_days=unknown, t.a_sev_intake_days=5 unknown
derived: a_mod_intake intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days intake_pct=unknown, t.a_mod_intake_pct=75, intake_days=unknown, t.a_mod_intake_days=7 unknown
derived: a_sev_wt (wt_loss_days <= 7 and wt_loss_pct > 2) or (wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5) wt_loss_days=unknown, wt_loss_pct=unknown unknown
derived: a_mod_wt (wt_loss_days <= 7 and wt_loss_pct >= 1) or (wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5) wt_loss_days=unknown, wt_loss_pct=unknown unknown
derived: c_sev_intake intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days intake_pct=unknown, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30 unknown
derived: c_mod_intake intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days intake_pct=unknown, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30 unknown
derived: c_sev_wt (wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5) or (wt_loss_days <= 183 and wt_loss_pct > 10) or (wt_loss_days <= 366 and wt_loss_pct > 20) wt_loss_days=unknown, wt_loss_pct=unknown unknown
derived: c_mod_wt (wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5) or (wt_loss_days <= 183 and wt_loss_pct >= 10) or (wt_loss_days <= 366 and wt_loss_pct >= 20) wt_loss_days=unknown, wt_loss_pct=unknown unknown
derived: n_assessed known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced) intake_pct=unknown, wt_loss_pct=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown 0
derived: n_severe case(nutr_context == 'acute', count(a_sev_intake, a_sev_wt, fat_loss >= 2, muscle_loss >= 2, fluid >= 2, grip_reduced), nutr_context == 'chronic', count(c_sev_intake, c_sev_wt, fat_loss >= 3, muscle_loss >= 3, fluid >= 3, grip_reduced), null) nutr_context=unknown, a_sev_intake=unknown, a_sev_wt=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown, c_sev_intake=unknown, c_sev_wt=unknown unknown
derived: n_moderate case(nutr_context == 'acute', count(a_sev_intake or a_mod_intake, a_sev_wt or a_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), nutr_context == 'chronic', count(c_sev_intake or c_mod_intake, c_sev_wt or c_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), null) nutr_context=unknown, a_sev_intake=unknown, a_mod_intake=unknown, a_sev_wt=unknown, a_mod_wt=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown, c_sev_intake=unknown, c_mod_intake=unknown, c_sev_wt=unknown, c_mod_wt=unknown unknown
outcome: severe n_severe >= 2 n_severe=unknown unknown
outcome: moderate n_moderate >= 2 n_moderate=unknown unknown
outcome: one_characteristic n_moderate == 1 n_moderate=unknown unknown
outcome: not_met n_moderate == 0 and n_assessed >= 2 n_moderate=unknown, n_assessed=0 false
Obesity Criteria 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=73, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=38.5, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=38.5, 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=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=36.7, 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=10.38, t.wbc_hi=12, wbc_min_48h=9.74, 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=0.43 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=75.0 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=2.72 2
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=0.83 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=2, sofa_renal_baseline=0 2
derived: sepsis3 infection_documented and sofa_delta >= t.sofa_delta infection_documented=False, sofa_delta=2, 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 (49)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-001291Wed Oct 01, 2025 09:15 AMcreatinine0.8 mg/dL
LAB-001292Mon Sep 14, 2026 10:05 AMcreatinine0.83 mg/dL
LAB-001293Thu Oct 29, 2026 05:47 PMcreatinine2.12 mg/dL
LAB-001302Thu Oct 29, 2026 05:47 PMbnp1060.0 pg/mL
LAB-001303Thu Oct 29, 2026 05:47 PMsodium141.0 mmol/L
LAB-001312Thu Oct 29, 2026 05:47 PMhemoglobin13.72 g/dL
LAB-001321Thu Oct 29, 2026 05:47 PMwbc10.38 x10^3/uL
LAB-001322Thu Oct 29, 2026 05:47 PMplatelets274.0 x10^3/uL
LAB-001339Thu Oct 29, 2026 05:47 PMbilirubin0.43 mg/dL
LAB-001294Fri Oct 30, 2026 05:00 AMcreatinine2.72 mg/dL
LAB-001304Fri Oct 30, 2026 05:00 AMsodium138.0 mmol/L
LAB-001313Fri Oct 30, 2026 05:00 AMhemoglobin13.61 g/dL
LAB-001323Fri Oct 30, 2026 05:00 AMwbc10.2 x10^3/uL
LAB-001324Fri Oct 30, 2026 05:00 AMplatelets211.0 x10^3/uL
LAB-001295Sat Oct 31, 2026 05:00 AMcreatinine2.45 mg/dL
LAB-001305Sat Oct 31, 2026 05:00 AMsodium139.0 mmol/L
LAB-001314Sat Oct 31, 2026 05:00 AMhemoglobin13.73 g/dL
LAB-001325Sat Oct 31, 2026 05:00 AMwbc9.74 x10^3/uL
LAB-001326Sat Oct 31, 2026 05:00 AMplatelets188.0 x10^3/uL
LAB-001296Sun Nov 01, 2026 05:00 AMcreatinine2.04 mg/dL
LAB-001306Sun Nov 01, 2026 05:00 AMsodium136.0 mmol/L
LAB-001315Sun Nov 01, 2026 05:00 AMhemoglobin14.02 g/dL
LAB-001327Sun Nov 01, 2026 05:00 AMwbc7.42 x10^3/uL
LAB-001328Sun Nov 01, 2026 05:00 AMplatelets189.0 x10^3/uL
LAB-001297Mon Nov 02, 2026 05:00 AMcreatinine1.68 mg/dL
LAB-001307Mon Nov 02, 2026 05:00 AMsodium138.0 mmol/L
LAB-001316Mon Nov 02, 2026 05:00 AMhemoglobin13.81 g/dL
LAB-001329Mon Nov 02, 2026 05:00 AMwbc5.7 x10^3/uL
LAB-001330Mon Nov 02, 2026 05:00 AMplatelets280.0 x10^3/uL
LAB-001298Tue Nov 03, 2026 05:00 AMcreatinine1.49 mg/dL
LAB-001308Tue Nov 03, 2026 05:00 AMsodium139.0 mmol/L
LAB-001317Tue Nov 03, 2026 05:00 AMhemoglobin13.55 g/dL
LAB-001331Tue Nov 03, 2026 05:00 AMwbc10.86 x10^3/uL
LAB-001332Tue Nov 03, 2026 05:00 AMplatelets208.0 x10^3/uL
LAB-001299Wed Nov 04, 2026 05:00 AMcreatinine1.36 mg/dL
LAB-001309Wed Nov 04, 2026 05:00 AMsodium142.0 mmol/L
LAB-001318Wed Nov 04, 2026 05:00 AMhemoglobin13.55 g/dL
LAB-001333Wed Nov 04, 2026 05:00 AMwbc5.96 x10^3/uL
LAB-001334Wed Nov 04, 2026 05:00 AMplatelets247.0 x10^3/uL
LAB-001300Thu Nov 05, 2026 05:00 AMcreatinine1.3 mg/dL
LAB-001310Thu Nov 05, 2026 05:00 AMsodium138.0 mmol/L
LAB-001319Thu Nov 05, 2026 05:00 AMhemoglobin14.06 g/dL
LAB-001335Thu Nov 05, 2026 05:00 AMwbc7.71 x10^3/uL
LAB-001336Thu Nov 05, 2026 05:00 AMplatelets291.0 x10^3/uL
LAB-001301Fri Nov 06, 2026 05:00 AMcreatinine1.28 mg/dL
LAB-001311Fri Nov 06, 2026 05:00 AMsodium142.0 mmol/L
LAB-001320Fri Nov 06, 2026 05:00 AMhemoglobin13.58 g/dL
LAB-001337Fri Nov 06, 2026 05:00 AMwbc10.64 x10^3/uL
LAB-001338Fri Nov 06, 2026 05:00 AMplatelets217.0 x10^3/uL
Vitals (144)
Vitals
RowWhenKindValueDetail
VIT-003720Thu Oct 29, 2026 05:07 PMspo295.0room air
VIT-003721Thu Oct 29, 2026 05:07 PMrr14.0
VIT-003768Thu Oct 29, 2026 05:07 PMtemp_c37.4
VIT-003769Thu Oct 29, 2026 05:07 PMhr82.0
VIT-003770Thu Oct 29, 2026 05:07 PMmap79.0
VIT-003771Thu Oct 29, 2026 05:07 PMgcs15.0
VIT-003722Fri Oct 30, 2026 01:07 AMspo299.0room air
VIT-003723Fri Oct 30, 2026 01:07 AMrr16.0
VIT-003772Fri Oct 30, 2026 01:07 AMtemp_c37.2
VIT-003773Fri Oct 30, 2026 01:07 AMhr86.0
VIT-003774Fri Oct 30, 2026 01:07 AMmap78.0
VIT-003775Fri Oct 30, 2026 01:07 AMgcs15.0
VIT-003724Fri Oct 30, 2026 09:07 AMspo294.0room air
VIT-003725Fri Oct 30, 2026 09:07 AMrr19.0
VIT-003776Fri Oct 30, 2026 09:07 AMtemp_c37.0
VIT-003777Fri Oct 30, 2026 09:07 AMhr74.0
VIT-003778Fri Oct 30, 2026 09:07 AMmap81.0
VIT-003779Fri Oct 30, 2026 09:07 AMgcs15.0
VIT-003726Fri Oct 30, 2026 05:07 PMspo299.0room air
VIT-003727Fri Oct 30, 2026 05:07 PMrr20.0
VIT-003780Fri Oct 30, 2026 05:07 PMtemp_c36.7
VIT-003781Fri Oct 30, 2026 05:07 PMhr79.0
VIT-003782Fri Oct 30, 2026 05:07 PMmap75.0
VIT-003783Fri Oct 30, 2026 05:07 PMgcs15.0
VIT-003728Sat Oct 31, 2026 01:07 AMspo295.0room air
VIT-003729Sat Oct 31, 2026 01:07 AMrr19.0
VIT-003784Sat Oct 31, 2026 01:07 AMtemp_c37.3
VIT-003785Sat Oct 31, 2026 01:07 AMhr72.0
VIT-003786Sat Oct 31, 2026 01:07 AMmap84.0
VIT-003787Sat Oct 31, 2026 01:07 AMgcs15.0
VIT-003730Sat Oct 31, 2026 09:07 AMspo296.0room air
VIT-003731Sat Oct 31, 2026 09:07 AMrr20.0
VIT-003788Sat Oct 31, 2026 09:07 AMtemp_c36.7
VIT-003789Sat Oct 31, 2026 09:07 AMhr73.0
VIT-003790Sat Oct 31, 2026 09:07 AMmap84.0
VIT-003791Sat Oct 31, 2026 09:07 AMgcs15.0
VIT-003732Sat Oct 31, 2026 05:07 PMspo296.0room air
VIT-003733Sat Oct 31, 2026 05:07 PMrr17.0
VIT-003792Sat Oct 31, 2026 05:07 PMtemp_c37.1
VIT-003793Sat Oct 31, 2026 05:07 PMhr81.0
VIT-003794Sat Oct 31, 2026 05:07 PMmap74.0
VIT-003795Sat Oct 31, 2026 05:07 PMgcs15.0
VIT-003734Sun Nov 01, 2026 01:07 AMspo295.0room air
VIT-003735Sun Nov 01, 2026 01:07 AMrr14.0
VIT-003796Sun Nov 01, 2026 01:07 AMtemp_c36.9
VIT-003797Sun Nov 01, 2026 01:07 AMhr78.0
VIT-003798Sun Nov 01, 2026 01:07 AMmap87.0
VIT-003799Sun Nov 01, 2026 01:07 AMgcs15.0
VIT-003736Sun Nov 01, 2026 09:07 AMspo298.0room air
VIT-003737Sun Nov 01, 2026 09:07 AMrr15.0
VIT-003800Sun Nov 01, 2026 09:07 AMtemp_c37.0
VIT-003801Sun Nov 01, 2026 09:07 AMhr87.0
VIT-003802Sun Nov 01, 2026 09:07 AMmap83.0
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VIT-003804Sun Nov 01, 2026 05:07 PMtemp_c36.6
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VIT-003740Mon Nov 02, 2026 01:07 AMspo295.0room air
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VIT-003742Mon Nov 02, 2026 09:07 AMspo297.0room air
VIT-003743Mon Nov 02, 2026 09:07 AMrr16.0
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VIT-003747Tue Nov 03, 2026 01:07 AMrr18.0
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Medications, orders, echo, history (8)

Notes

History and physical · DOC-000126 · Dr. Gideon Zeller (attending) · Thu Oct 29, 2026 07:47 PM

Source document DOC-000126: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Wes Stavros   MRN: MRN57794122   Admitted: 2026-10-29 16:47
Service: Pulmonology   Attending: Dr. Gideon Zeller

History of present illness: 73-year-old woman admitted with COPD exacerbation. 
Past medical history: heart failure with reduced ejection fraction.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. COPD exacerbation: bronchodilators and steroids.

Progress note · DOC-000127 · Dr. Gideon Zeller (attending) · Sat Oct 31, 2026 04:47 PM

Source document DOC-000127: Progress note (synthetic)
PROGRESS NOTE (Attending)
Patient: Wes Stavros   MRN: MRN57794122   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. COPD exacerbation: continue current management.
2. Obesity: counsel on weight.
3. Acute kidney injury: trend creatinine, hold nephrotoxins, strict intake and output.
4. HFrEF: diuresis and daily weights; monitor electrolytes.

Attending: Dr. Gideon Zeller

Discharge summary · DOC-000128 · Dr. Gideon Zeller (attending) · Fri Nov 06, 2026 03:40 PM

Source document DOC-000128: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Wes Stavros   MRN: MRN57794122
Admitted 2026-10-29; discharged 2026-11-06.

Discharge diagnoses:
- COPD exacerbation
- obesity
- acute kidney injury
- HFrEF

Disposition: home with follow-up.