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-00056: Nadia Foxhall

88F · MRN75791845 · Pulmonology · admitted Thu Oct 29, 2026 08:39 AM · discharged Fri Nov 06, 2026 12:09 PM · attending Dr. Gideon Zeller · resident Dr. Noor Halvorsen · 155 cm, 77.5 kg

Documented diagnoses (current)

  • Principal: “COPD exacerbation” · J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
  • “obesity” · E66.9 Obesity, unspecified

Illustrative grouping now: MS-DRG 192 Chronic obstructive pulmonary disease without CC/MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 191.

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 Specificity gap Criteria support Acute kidney injury (KDIGO stage 2) (N17.9); no corresponding diagnosis is documented.
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=2.313, t.ratio_s1=1.5, creat_rise_48h=0.34, t.rise_abs=0.3, uo_hours_lt_0_5=18, 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=2.313, t.ratio_s3=3.0, creat_peak=1.55, t.scr_s3=4.0, rrt_started=False, uo_hours_lt_0_3=0, t.uo_s3_h=24, anuria_hours=0, 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=2.313, t.ratio_s2=2.0, uo_hours_lt_0_5=18, t.uo_s2_h=12 true
derived: stage case(stage3, 3, stage2, 2, meets_definition, 1, 0) stage3=False, stage2=True, meets_definition=True 2
derived: baseline_independent creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started creat_baseline_known=True, creat_rise_48h=0.34, t.rise_abs=0.3, rrt_started=False true
outcome: aki_staged stage >= 1 and baseline_independent stage=2, 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=12.67, 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=12.67, 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=247, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=84.6, egfr_late=84.0 84.6
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=84.6, t.g2=60, egfr_late=84.0 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=84.6, 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=84.6, egfr_late=84.0, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=84.6, t.g2=60 true
Heart failure Insufficient data No gap Insufficient data: the criteria could not be applied.
Trace
Rule trace (rule heart_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
StepExpressionInputs and thresholds readResult
derived: np_elevated coalesce(bnp_max >= t.bnp, false) or coalesce(ntprobnp_max >= t.ntprobnp, false) bnp_max=unknown, t.bnp=100, ntprobnp_max=unknown, t.ntprobnp=300 false
derived: acute_count count(iv_loop_diuretic, np_elevated, new_o2) iv_loop_diuretic=False, np_elevated=False, new_o2=False 0
derived: hf_type case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange') lvef=unknown, t.ref=40, t.pres=50 unknown
derived: improved coalesce(lvef_prior_min <= t.ref and lvef > t.ref and lvef - lvef_prior_min >= t.improved_rise, false) lvef_prior_min=unknown, t.ref=40, lvef=unknown, t.improved_rise=10 false
derived: acuity case(acute_count >= 2 and hf_history, 'acute on chronic', acute_count >= 2, 'acute', acute_count == 0 and hf_history, 'chronic', null) acute_count=0, hf_history=False unknown
outcome: improved_ef improved improved=False false
outcome: midrange hf_type == 'midrange' hf_type=unknown unknown
outcome: sys_aoc hf_type == 'systolic' and acuity == 'acute on chronic' hf_type=unknown, acuity=unknown unknown
outcome: sys_acute hf_type == 'systolic' and acuity == 'acute' hf_type=unknown, acuity=unknown unknown
outcome: sys_chronic hf_type == 'systolic' and acuity == 'chronic' hf_type=unknown, acuity=unknown unknown
outcome: dia_aoc hf_type == 'diastolic' and acuity == 'acute on chronic' hf_type=unknown, acuity=unknown unknown
outcome: dia_acute hf_type == 'diastolic' and acuity == 'acute' hf_type=unknown, acuity=unknown unknown
outcome: dia_chronic hf_type == 'diastolic' and acuity == 'chronic' hf_type=unknown, acuity=unknown unknown
outcome: one_indicator acute_count == 1 acute_count=0 false
Hyponatraemia Criteria met Specificity gap Criteria support Hyponatraemia (profound) (E87.1); no corresponding diagnosis is documented.
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=121.0, t.profound=125, t.moderate=130, t.low=135 profound
outcome: met na_min < t.low and na_low_count >= t.repeat and na_treated na_min=121.0, t.low=135, na_low_count=6, t.repeat=2, na_treated=True 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 1 (E66.811).
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=88, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=32.3, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=32.3, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=32.3, 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=90.0, 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=10.49, t.wbc_hi=12, wbc_min_48h=6.09, 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=181.0 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=0.51 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=1.55 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=0.67 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=1, sofa_renal_baseline=0 1
derived: sepsis3 infection_documented and sofa_delta >= t.sofa_delta infection_documented=False, sofa_delta=1, 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 (48)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-001871Wed Nov 05, 2025 09:15 AMcreatinine0.65 mg/dL
LAB-001872Sat Jul 11, 2026 10:05 AMcreatinine0.67 mg/dL
LAB-001873Thu Oct 29, 2026 09:39 AMcreatinine1.21 mg/dL
LAB-001882Thu Oct 29, 2026 09:39 AMsodium123.0 mmol/L
LAB-001891Thu Oct 29, 2026 09:39 AMhemoglobin12.84 g/dL
LAB-001900Thu Oct 29, 2026 09:39 AMwbc10.49 x10^3/uL
LAB-001901Thu Oct 29, 2026 09:39 AMplatelets267.0 x10^3/uL
LAB-001918Thu Oct 29, 2026 09:39 AMbilirubin0.51 mg/dL
LAB-001874Fri Oct 30, 2026 05:00 AMcreatinine1.55 mg/dL
LAB-001883Fri Oct 30, 2026 05:00 AMsodium121.0 mmol/L
LAB-001892Fri Oct 30, 2026 05:00 AMhemoglobin13.16 g/dL
LAB-001902Fri Oct 30, 2026 05:00 AMwbc6.09 x10^3/uL
LAB-001903Fri Oct 30, 2026 05:00 AMplatelets181.0 x10^3/uL
LAB-001875Sat Oct 31, 2026 05:00 AMcreatinine1.4 mg/dL
LAB-001884Sat Oct 31, 2026 05:00 AMsodium122.0 mmol/L
LAB-001893Sat Oct 31, 2026 05:00 AMhemoglobin13.2 g/dL
LAB-001904Sat Oct 31, 2026 05:00 AMwbc9.47 x10^3/uL
LAB-001905Sat Oct 31, 2026 05:00 AMplatelets185.0 x10^3/uL
LAB-001876Sun Nov 01, 2026 05:00 AMcreatinine1.17 mg/dL
LAB-001885Sun Nov 01, 2026 05:00 AMsodium125.0 mmol/L
LAB-001894Sun Nov 01, 2026 05:00 AMhemoglobin12.77 g/dL
LAB-001906Sun Nov 01, 2026 05:00 AMwbc6.4 x10^3/uL
LAB-001907Sun Nov 01, 2026 05:00 AMplatelets171.0 x10^3/uL
LAB-001877Mon Nov 02, 2026 05:00 AMcreatinine0.96 mg/dL
LAB-001886Mon Nov 02, 2026 05:00 AMsodium127.0 mmol/L
LAB-001895Mon Nov 02, 2026 05:00 AMhemoglobin12.99 g/dL
LAB-001908Mon Nov 02, 2026 05:00 AMwbc8.1 x10^3/uL
LAB-001909Mon Nov 02, 2026 05:00 AMplatelets286.0 x10^3/uL
LAB-001878Tue Nov 03, 2026 05:00 AMcreatinine0.86 mg/dL
LAB-001887Tue Nov 03, 2026 05:00 AMsodium134.0 mmol/L
LAB-001896Tue Nov 03, 2026 05:00 AMhemoglobin12.67 g/dL
LAB-001910Tue Nov 03, 2026 05:00 AMwbc10.13 x10^3/uL
LAB-001911Tue Nov 03, 2026 05:00 AMplatelets235.0 x10^3/uL
LAB-001879Wed Nov 04, 2026 05:00 AMcreatinine0.78 mg/dL
LAB-001888Wed Nov 04, 2026 05:00 AMsodium136.0 mmol/L
LAB-001897Wed Nov 04, 2026 05:00 AMhemoglobin12.74 g/dL
LAB-001912Wed Nov 04, 2026 05:00 AMwbc6.84 x10^3/uL
LAB-001913Wed Nov 04, 2026 05:00 AMplatelets173.0 x10^3/uL
LAB-001880Thu Nov 05, 2026 05:00 AMcreatinine0.75 mg/dL
LAB-001889Thu Nov 05, 2026 05:00 AMsodium137.0 mmol/L
LAB-001898Thu Nov 05, 2026 05:00 AMhemoglobin12.95 g/dL
LAB-001914Thu Nov 05, 2026 05:00 AMwbc7.69 x10^3/uL
LAB-001915Thu Nov 05, 2026 05:00 AMplatelets293.0 x10^3/uL
LAB-001881Fri Nov 06, 2026 05:00 AMcreatinine0.73 mg/dL
LAB-001890Fri Nov 06, 2026 05:00 AMsodium137.0 mmol/L
LAB-001899Fri Nov 06, 2026 05:00 AMhemoglobin12.78 g/dL
LAB-001916Fri Nov 06, 2026 05:00 AMwbc7.44 x10^3/uL
LAB-001917Fri Nov 06, 2026 05:00 AMplatelets188.0 x10^3/uL
Vitals (158)
Vitals
RowWhenKindValueDetail
VIT-005375Thu Oct 29, 2026 08:59 AMspo299.0room air
VIT-005376Thu Oct 29, 2026 08:59 AMrr17.0
VIT-005425Thu Oct 29, 2026 08:59 AMtemp_c37.5
VIT-005426Thu Oct 29, 2026 08:59 AMhr85.0
VIT-005427Thu Oct 29, 2026 08:59 AMmap83.0
VIT-005428Thu Oct 29, 2026 08:59 AMgcs15.0
VIT-005367Thu Oct 29, 2026 02:39 PMurine_ml_6h511.5
VIT-005377Thu Oct 29, 2026 04:59 PMspo294.0room air
VIT-005378Thu Oct 29, 2026 04:59 PMrr18.0
VIT-005429Thu Oct 29, 2026 04:59 PMtemp_c37.5
VIT-005430Thu Oct 29, 2026 04:59 PMhr90.0
VIT-005431Thu Oct 29, 2026 04:59 PMmap92.0
VIT-005432Thu Oct 29, 2026 04:59 PMgcs15.0
VIT-005368Thu Oct 29, 2026 08:39 PMurine_ml_6h195.3
VIT-005379Fri Oct 30, 2026 12:59 AMspo297.0room air
VIT-005380Fri Oct 30, 2026 12:59 AMrr14.0
VIT-005433Fri Oct 30, 2026 12:59 AMtemp_c37.3
VIT-005434Fri Oct 30, 2026 12:59 AMhr80.0
VIT-005435Fri Oct 30, 2026 12:59 AMmap89.0
VIT-005436Fri Oct 30, 2026 12:59 AMgcs15.0
VIT-005369Fri Oct 30, 2026 02:39 AMurine_ml_6h195.3
VIT-005370Fri Oct 30, 2026 08:39 AMurine_ml_6h195.3
VIT-005381Fri Oct 30, 2026 08:59 AMspo297.0room air
VIT-005382Fri Oct 30, 2026 08:59 AMrr18.0
VIT-005437Fri Oct 30, 2026 08:59 AMtemp_c36.8
VIT-005438Fri Oct 30, 2026 08:59 AMhr74.0
VIT-005439Fri Oct 30, 2026 08:59 AMmap87.0
VIT-005440Fri Oct 30, 2026 08:59 AMgcs15.0
VIT-005371Fri Oct 30, 2026 02:39 PMurine_ml_6h511.5
VIT-005383Fri Oct 30, 2026 04:59 PMspo297.0room air
VIT-005384Fri Oct 30, 2026 04:59 PMrr20.0
VIT-005441Fri Oct 30, 2026 04:59 PMtemp_c37.2
VIT-005442Fri Oct 30, 2026 04:59 PMhr83.0
VIT-005443Fri Oct 30, 2026 04:59 PMmap90.0
VIT-005444Fri Oct 30, 2026 04:59 PMgcs15.0
VIT-005372Fri Oct 30, 2026 08:39 PMurine_ml_6h511.5
VIT-005385Sat Oct 31, 2026 12:59 AMspo294.0room air
VIT-005386Sat Oct 31, 2026 12:59 AMrr14.0
VIT-005445Sat Oct 31, 2026 12:59 AMtemp_c36.6
VIT-005446Sat Oct 31, 2026 12:59 AMhr76.0
VIT-005447Sat Oct 31, 2026 12:59 AMmap78.0
VIT-005448Sat Oct 31, 2026 12:59 AMgcs15.0
VIT-005373Sat Oct 31, 2026 02:39 AMurine_ml_6h511.5
VIT-005374Sat Oct 31, 2026 08:39 AMurine_ml_6h511.5
VIT-005387Sat Oct 31, 2026 08:59 AMspo298.0room air
VIT-005388Sat Oct 31, 2026 08:59 AMrr19.0
VIT-005449Sat Oct 31, 2026 08:59 AMtemp_c37.5
VIT-005450Sat Oct 31, 2026 08:59 AMhr80.0
VIT-005451Sat Oct 31, 2026 08:59 AMmap87.0
VIT-005452Sat Oct 31, 2026 08:59 AMgcs15.0
VIT-005389Sat Oct 31, 2026 04:59 PMspo297.0room air
VIT-005390Sat Oct 31, 2026 04:59 PMrr15.0
VIT-005453Sat Oct 31, 2026 04:59 PMtemp_c37.3
VIT-005454Sat Oct 31, 2026 04:59 PMhr70.0
VIT-005455Sat Oct 31, 2026 04:59 PMmap78.0
VIT-005456Sat Oct 31, 2026 04:59 PMgcs15.0
VIT-005391Sun Nov 01, 2026 12:59 AMspo297.0room air
VIT-005392Sun Nov 01, 2026 12:59 AMrr18.0
VIT-005457Sun Nov 01, 2026 12:59 AMtemp_c37.4
VIT-005458Sun Nov 01, 2026 12:59 AMhr90.0
VIT-005459Sun Nov 01, 2026 12:59 AMmap87.0
VIT-005460Sun Nov 01, 2026 12:59 AMgcs15.0
VIT-005393Sun Nov 01, 2026 08:59 AMspo294.0room air
VIT-005394Sun Nov 01, 2026 08:59 AMrr20.0
VIT-005461Sun Nov 01, 2026 08:59 AMtemp_c36.5
VIT-005462Sun Nov 01, 2026 08:59 AMhr81.0
VIT-005463Sun Nov 01, 2026 08:59 AMmap76.0
VIT-005464Sun Nov 01, 2026 08:59 AMgcs15.0
VIT-005395Sun Nov 01, 2026 04:59 PMspo296.0room air
VIT-005396Sun Nov 01, 2026 04:59 PMrr16.0
VIT-005465Sun Nov 01, 2026 04:59 PMtemp_c37.3
VIT-005466Sun Nov 01, 2026 04:59 PMhr91.0
VIT-005467Sun Nov 01, 2026 04:59 PMmap87.0
VIT-005468Sun Nov 01, 2026 04:59 PMgcs15.0
VIT-005397Mon Nov 02, 2026 12:59 AMspo297.0room air
VIT-005398Mon Nov 02, 2026 12:59 AMrr19.0
VIT-005469Mon Nov 02, 2026 12:59 AMtemp_c36.9
VIT-005470Mon Nov 02, 2026 12:59 AMhr87.0
VIT-005471Mon Nov 02, 2026 12:59 AMmap89.0
VIT-005472Mon Nov 02, 2026 12:59 AMgcs15.0
VIT-005399Mon Nov 02, 2026 08:59 AMspo295.0room air
VIT-005400Mon Nov 02, 2026 08:59 AMrr17.0
VIT-005473Mon Nov 02, 2026 08:59 AMtemp_c37.2
VIT-005474Mon Nov 02, 2026 08:59 AMhr76.0
VIT-005475Mon Nov 02, 2026 08:59 AMmap76.0
VIT-005476Mon Nov 02, 2026 08:59 AMgcs15.0
VIT-005401Mon Nov 02, 2026 04:59 PMspo295.0room air
VIT-005402Mon Nov 02, 2026 04:59 PMrr14.0
VIT-005477Mon Nov 02, 2026 04:59 PMtemp_c37.3
VIT-005478Mon Nov 02, 2026 04:59 PMhr76.0
VIT-005479Mon Nov 02, 2026 04:59 PMmap89.0
VIT-005480Mon Nov 02, 2026 04:59 PMgcs15.0
VIT-005403Tue Nov 03, 2026 12:59 AMspo294.0room air
VIT-005404Tue Nov 03, 2026 12:59 AMrr15.0
VIT-005481Tue Nov 03, 2026 12:59 AMtemp_c37.2
VIT-005482Tue Nov 03, 2026 12:59 AMhr75.0
VIT-005483Tue Nov 03, 2026 12:59 AMmap76.0
VIT-005484Tue Nov 03, 2026 12:59 AMgcs15.0
VIT-005405Tue Nov 03, 2026 08:59 AMspo298.0room air
VIT-005406Tue Nov 03, 2026 08:59 AMrr16.0
VIT-005485Tue Nov 03, 2026 08:59 AMtemp_c36.8
VIT-005486Tue Nov 03, 2026 08:59 AMhr83.0
VIT-005487Tue Nov 03, 2026 08:59 AMmap89.0
VIT-005488Tue Nov 03, 2026 08:59 AMgcs15.0
VIT-005407Tue Nov 03, 2026 04:59 PMspo298.0room air
VIT-005408Tue Nov 03, 2026 04:59 PMrr17.0
VIT-005489Tue Nov 03, 2026 04:59 PMtemp_c37.1
VIT-005490Tue Nov 03, 2026 04:59 PMhr87.0
VIT-005491Tue Nov 03, 2026 04:59 PMmap90.0
VIT-005492Tue Nov 03, 2026 04:59 PMgcs15.0
VIT-005409Wed Nov 04, 2026 12:59 AMspo297.0room air
VIT-005410Wed Nov 04, 2026 12:59 AMrr14.0
VIT-005493Wed Nov 04, 2026 12:59 AMtemp_c36.7
VIT-005494Wed Nov 04, 2026 12:59 AMhr83.0
VIT-005495Wed Nov 04, 2026 12:59 AMmap92.0
VIT-005496Wed Nov 04, 2026 12:59 AMgcs15.0
VIT-005411Wed Nov 04, 2026 08:59 AMspo297.0room air
VIT-005412Wed Nov 04, 2026 08:59 AMrr20.0
VIT-005497Wed Nov 04, 2026 08:59 AMtemp_c36.8
VIT-005498Wed Nov 04, 2026 08:59 AMhr71.0
VIT-005499Wed Nov 04, 2026 08:59 AMmap80.0
VIT-005500Wed Nov 04, 2026 08:59 AMgcs15.0
VIT-005413Wed Nov 04, 2026 04:59 PMspo295.0room air
VIT-005414Wed Nov 04, 2026 04:59 PMrr19.0
VIT-005501Wed Nov 04, 2026 04:59 PMtemp_c36.9
VIT-005502Wed Nov 04, 2026 04:59 PMhr76.0
VIT-005503Wed Nov 04, 2026 04:59 PMmap81.0
VIT-005504Wed Nov 04, 2026 04:59 PMgcs15.0
VIT-005415Thu Nov 05, 2026 12:59 AMspo295.0room air
VIT-005416Thu Nov 05, 2026 12:59 AMrr16.0
VIT-005505Thu Nov 05, 2026 12:59 AMtemp_c37.0
VIT-005506Thu Nov 05, 2026 12:59 AMhr69.0
VIT-005507Thu Nov 05, 2026 12:59 AMmap88.0
VIT-005508Thu Nov 05, 2026 12:59 AMgcs15.0
VIT-005417Thu Nov 05, 2026 08:59 AMspo297.0room air
VIT-005418Thu Nov 05, 2026 08:59 AMrr19.0
VIT-005509Thu Nov 05, 2026 08:59 AMtemp_c36.6
VIT-005510Thu Nov 05, 2026 08:59 AMhr84.0
VIT-005511Thu Nov 05, 2026 08:59 AMmap89.0
VIT-005512Thu Nov 05, 2026 08:59 AMgcs15.0
VIT-005419Thu Nov 05, 2026 04:59 PMspo296.0room air
VIT-005420Thu Nov 05, 2026 04:59 PMrr15.0
VIT-005513Thu Nov 05, 2026 04:59 PMtemp_c36.9
VIT-005514Thu Nov 05, 2026 04:59 PMhr90.0
VIT-005515Thu Nov 05, 2026 04:59 PMmap75.0
VIT-005516Thu Nov 05, 2026 04:59 PMgcs15.0
VIT-005421Fri Nov 06, 2026 12:59 AMspo294.0room air
VIT-005422Fri Nov 06, 2026 12:59 AMrr18.0
VIT-005517Fri Nov 06, 2026 12:59 AMtemp_c37.1
VIT-005518Fri Nov 06, 2026 12:59 AMhr71.0
VIT-005519Fri Nov 06, 2026 12:59 AMmap86.0
VIT-005520Fri Nov 06, 2026 12:59 AMgcs15.0
VIT-005423Fri Nov 06, 2026 08:59 AMspo294.0room air
VIT-005424Fri Nov 06, 2026 08:59 AMrr17.0
VIT-005521Fri Nov 06, 2026 08:59 AMtemp_c36.6
VIT-005522Fri Nov 06, 2026 08:59 AMhr88.0
VIT-005523Fri Nov 06, 2026 08:59 AMmap81.0
VIT-005524Fri Nov 06, 2026 08:59 AMgcs15.0
Medications, orders, echo, history (2)

Notes

History and physical · DOC-000194 · Dr. Noor Halvorsen (resident) · Thu Oct 29, 2026 11:39 AM

Source document DOC-000194: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Nadia Foxhall   MRN: MRN75791845   Admitted: 2026-10-29 08:39
Service: Pulmonology   Attending: Dr. Gideon Zeller

History of present illness: 88-year-old woman admitted with COPD exacerbation. 
Past medical history: none significant.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. COPD exacerbation: bronchodilators and steroids.

Nutrition assessment · DOC-000193 · Vera Pemberton, RD (dietitian) · Fri Oct 30, 2026 12:39 PM

Cited facts from this note (5)
fat_loss
none · cited p. 1, line 7 · confidence 0.90
Show source for fat_loss
… MRN: MRN75791845 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: Nadia Foxhall MRN: MRN75791845 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: Nadia Foxhall MRN: MRN75791845 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-000193: Nutrition assessment (synthetic)
NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Nadia Foxhall   MRN: MRN75791845

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-000195 · Dr. Noor Halvorsen (resident) · Sat Oct 31, 2026 10:39 AM

Source document DOC-000195: Progress note (synthetic)
PROGRESS NOTE (Resident)
Patient: Nadia Foxhall   MRN: MRN75791845   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.

Resident: Dr. Noor Halvorsen   Attending cosign: completed

Discharge summary · DOC-000196 · Dr. Gideon Zeller (attending) · Fri Nov 06, 2026 12:09 PM

Source document DOC-000196: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Nadia Foxhall   MRN: MRN75791845
Admitted 2026-10-29; discharged 2026-11-06.

Discharge diagnoses:
- COPD exacerbation
- obesity

Disposition: home with follow-up.