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.

ENC-00058: Kenji Galloway

56M · MRN26501559 · Cardiology · admitted Wed Nov 04, 2026 05:55 PM · discharged Tue Nov 10, 2026 02:48 PM · attending Dr. Kenji Stavros · resident Dr. Elena Nakashima · 169 cm, 69.3 kg

Documented diagnoses (current)

Principal: “chronic diastolic heart failure” · I50.32 Chronic diastolic (congestive) heart failure
“hyponatremia” · E87.1 Hypo-osmolality and hyponatremia

Illustrative grouping now: MS-DRG 292 Heart failure and shock with CC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 293.

Queries and events

No queries yet.

All rules applied

Rule Criteria Finding Outcome

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)
Step	Expression	Inputs and thresholds read	Result
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=1.058, t.ratio_s1=1.5, creat_rise_48h=0.06, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, t.uo_s1_h=6	false
derived: stage3	`meets_definition and (creat_ratio >= t.ratio_s3 or creat_peak >= t.scr_s3 or rrt_started or coalesce(uo_hours_lt_0_3 >= t.uo_s3_h, false) or coalesce(anuria_hours >= t.anuria_h, false))`	meets_definition=False, creat_ratio=1.058, t.ratio_s3=3.0, creat_peak=1.63, 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=1.058, t.ratio_s2=2.0, uo_hours_lt_0_5=unknown, t.uo_s2_h=12	false
derived: stage	`case(stage3, 3, stage2, 2, meets_definition, 1, 0)`	stage3=False, stage2=False, meets_definition=False	0
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=0.06, t.rise_abs=0.3, rrt_started=False	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	stage=0, baseline_independent=True	false
outcome: aki_presumed_baseline	`stage >= 1`	stage=0	false
outcome: not_met	`stage == 0`	stage=0	true

Acute blood loss anaemia

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule blood_loss_anemia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: anaemic	`case(sex == 'M', hgb_nadir < t.hb_m, sex == 'F', hgb_nadir < t.hb_f, null)`	sex=M, hgb_nadir=14.76, 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=14.76, 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)
Step	Expression	Inputs and thresholds read	Result
derived: chronic	`egfr_n >= 2 and egfr_span_days >= t.chronic_days`	egfr_n=2, egfr_span_days=245, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=54.7, egfr_late=52.6	54.7
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=54.7, t.g2=60, egfr_late=52.6	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=54.7, 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=54.7, egfr_late=52.6, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=54.7, t.g2=60	false
outcome: g3a	`category == 'G3a'`	category=G3a	true

Heart failure

Criteria met

Specificity gap

Documented “chronic diastolic heart failure” (I50.32); criteria support the more specific Acute on chronic diastolic (HFpEF) heart failure (I50.33).

Trace

Rule trace (rule heart_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: np_elevated	`coalesce(bnp_max >= t.bnp, false) or coalesce(ntprobnp_max >= t.ntprobnp, false)`	bnp_max=1857.0, 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=55.0, t.ref=40, t.pres=50	diastolic
derived: improved	`coalesce(lvef_prior_min <= t.ref and lvef > t.ref and lvef - lvef_prior_min >= t.improved_rise, false)`	lvef_prior_min=unknown, t.ref=40, lvef=55.0, 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=diastolic	false
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	hf_type=diastolic, acuity=acute on chronic	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	hf_type=diastolic, acuity=acute on chronic	false
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	hf_type=diastolic, acuity=acute on chronic	false
outcome: dia_aoc	`hf_type == 'diastolic' and acuity == 'acute on chronic'`	hf_type=diastolic, acuity=acute on chronic	true

Hyponatraemia

Criteria not met

Clinical validation gap

Documented “hyponatremia” (E87.1) but the criteria are not met: All sodium values 135 or above (lowest 136).

Trace

Rule trace (rule hyponatremia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
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)
Step	Expression	Inputs and thresholds read	Result
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 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)
Step	Expression	Inputs and thresholds read	Result
outcome: not_adult	`age < t.adult`	age=56, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=24.3, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=24.3, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=24.3, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=24.3, 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)
Step	Expression	Inputs and thresholds read	Result
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)
Step	Expression	Inputs and thresholds read	Result
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)
Step	Expression	Inputs and thresholds read	Result
derived: sirs_temp	`coalesce(temp_max_48h > t.t_hi, false) or coalesce(temp_min_48h < t.t_lo, false)`	temp_max_48h=37.6, 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=83.0, 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=10.58, t.wbc_hi=12, wbc_min_48h=7.53, 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=225.0	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=0.56	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=1.63	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=1.54	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 (39)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-001958	Sat Dec 20, 2025 09:15 AM	creatinine	1.49 mg/dL
LAB-001959	Sun Aug 23, 2026 10:05 AM	creatinine	1.54 mg/dL
LAB-001960	Wed Nov 04, 2026 06:55 PM	creatinine	1.63 mg/dL
LAB-001967	Wed Nov 04, 2026 06:55 PM	bnp	1857.0 pg/mL
LAB-001968	Wed Nov 04, 2026 06:55 PM	sodium	136.0 mmol/L
LAB-001975	Wed Nov 04, 2026 06:55 PM	hemoglobin	14.89 g/dL
LAB-001982	Wed Nov 04, 2026 06:55 PM	wbc	10.58 x10^3/uL
LAB-001983	Wed Nov 04, 2026 06:55 PM	platelets	292.0 x10^3/uL
LAB-001996	Wed Nov 04, 2026 06:55 PM	bilirubin	0.56 mg/dL
LAB-001961	Thu Nov 05, 2026 05:00 AM	creatinine	1.52 mg/dL
LAB-001969	Thu Nov 05, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-001976	Thu Nov 05, 2026 05:00 AM	hemoglobin	15.15 g/dL
LAB-001984	Thu Nov 05, 2026 05:00 AM	wbc	7.53 x10^3/uL
LAB-001985	Thu Nov 05, 2026 05:00 AM	platelets	235.0 x10^3/uL
LAB-001962	Fri Nov 06, 2026 05:00 AM	creatinine	1.56 mg/dL
LAB-001970	Fri Nov 06, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-001977	Fri Nov 06, 2026 05:00 AM	hemoglobin	15.08 g/dL
LAB-001986	Fri Nov 06, 2026 05:00 AM	wbc	8.77 x10^3/uL
LAB-001987	Fri Nov 06, 2026 05:00 AM	platelets	225.0 x10^3/uL
LAB-001963	Sat Nov 07, 2026 05:00 AM	creatinine	1.55 mg/dL
LAB-001971	Sat Nov 07, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-001978	Sat Nov 07, 2026 05:00 AM	hemoglobin	15.16 g/dL
LAB-001988	Sat Nov 07, 2026 05:00 AM	wbc	6.77 x10^3/uL
LAB-001989	Sat Nov 07, 2026 05:00 AM	platelets	258.0 x10^3/uL
LAB-001964	Sun Nov 08, 2026 05:00 AM	creatinine	1.52 mg/dL
LAB-001972	Sun Nov 08, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-001979	Sun Nov 08, 2026 05:00 AM	hemoglobin	14.76 g/dL
LAB-001990	Sun Nov 08, 2026 05:00 AM	wbc	8.95 x10^3/uL
LAB-001991	Sun Nov 08, 2026 05:00 AM	platelets	185.0 x10^3/uL
LAB-001965	Mon Nov 09, 2026 05:00 AM	creatinine	1.58 mg/dL
LAB-001973	Mon Nov 09, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-001980	Mon Nov 09, 2026 05:00 AM	hemoglobin	15.24 g/dL
LAB-001992	Mon Nov 09, 2026 05:00 AM	wbc	7.27 x10^3/uL
LAB-001993	Mon Nov 09, 2026 05:00 AM	platelets	253.0 x10^3/uL
LAB-001966	Tue Nov 10, 2026 05:00 AM	creatinine	1.56 mg/dL
LAB-001974	Tue Nov 10, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-001981	Tue Nov 10, 2026 05:00 AM	hemoglobin	14.87 g/dL
LAB-001994	Tue Nov 10, 2026 05:00 AM	wbc	6.9 x10^3/uL
LAB-001995	Tue Nov 10, 2026 05:00 AM	platelets	210.0 x10^3/uL

Vitals (108)

Vitals
Row	When	Kind	Value	Detail
VIT-005639	Wed Nov 04, 2026 06:15 PM	spo2	98.0	room air
VIT-005640	Wed Nov 04, 2026 06:15 PM	rr	16.0
VIT-005675	Wed Nov 04, 2026 06:15 PM	temp_c	37.6
VIT-005676	Wed Nov 04, 2026 06:15 PM	hr	69.0
VIT-005677	Wed Nov 04, 2026 06:15 PM	map	81.0
VIT-005678	Wed Nov 04, 2026 06:15 PM	gcs	15.0
VIT-005641	Thu Nov 05, 2026 02:15 AM	spo2	97.0	room air
VIT-005642	Thu Nov 05, 2026 02:15 AM	rr	20.0
VIT-005679	Thu Nov 05, 2026 02:15 AM	temp_c	36.5
VIT-005680	Thu Nov 05, 2026 02:15 AM	hr	83.0
VIT-005681	Thu Nov 05, 2026 02:15 AM	map	87.0
VIT-005682	Thu Nov 05, 2026 02:15 AM	gcs	15.0
VIT-005643	Thu Nov 05, 2026 10:15 AM	spo2	98.0	room air
VIT-005644	Thu Nov 05, 2026 10:15 AM	rr	17.0
VIT-005683	Thu Nov 05, 2026 10:15 AM	temp_c	37.0
VIT-005684	Thu Nov 05, 2026 10:15 AM	hr	75.0
VIT-005685	Thu Nov 05, 2026 10:15 AM	map	81.0
VIT-005686	Thu Nov 05, 2026 10:15 AM	gcs	15.0
VIT-005645	Thu Nov 05, 2026 06:15 PM	spo2	94.0	room air
VIT-005646	Thu Nov 05, 2026 06:15 PM	rr	19.0
VIT-005687	Thu Nov 05, 2026 06:15 PM	temp_c	36.6
VIT-005688	Thu Nov 05, 2026 06:15 PM	hr	71.0
VIT-005689	Thu Nov 05, 2026 06:15 PM	map	86.0
VIT-005690	Thu Nov 05, 2026 06:15 PM	gcs	15.0
VIT-005647	Fri Nov 06, 2026 02:15 AM	spo2	97.0	room air
VIT-005648	Fri Nov 06, 2026 02:15 AM	rr	20.0
VIT-005691	Fri Nov 06, 2026 02:15 AM	temp_c	37.3
VIT-005692	Fri Nov 06, 2026 02:15 AM	hr	79.0
VIT-005693	Fri Nov 06, 2026 02:15 AM	map	79.0
VIT-005694	Fri Nov 06, 2026 02:15 AM	gcs	15.0
VIT-005649	Fri Nov 06, 2026 10:15 AM	spo2	97.0	room air
VIT-005650	Fri Nov 06, 2026 10:15 AM	rr	20.0
VIT-005695	Fri Nov 06, 2026 10:15 AM	temp_c	36.9
VIT-005696	Fri Nov 06, 2026 10:15 AM	hr	79.0
VIT-005697	Fri Nov 06, 2026 10:15 AM	map	82.0
VIT-005698	Fri Nov 06, 2026 10:15 AM	gcs	15.0
VIT-005651	Fri Nov 06, 2026 06:15 PM	spo2	97.0	room air
VIT-005652	Fri Nov 06, 2026 06:15 PM	rr	16.0
VIT-005699	Fri Nov 06, 2026 06:15 PM	temp_c	37.1
VIT-005700	Fri Nov 06, 2026 06:15 PM	hr	88.0
VIT-005701	Fri Nov 06, 2026 06:15 PM	map	81.0
VIT-005702	Fri Nov 06, 2026 06:15 PM	gcs	15.0
VIT-005653	Sat Nov 07, 2026 02:15 AM	spo2	99.0	room air
VIT-005654	Sat Nov 07, 2026 02:15 AM	rr	19.0
VIT-005703	Sat Nov 07, 2026 02:15 AM	temp_c	37.0
VIT-005704	Sat Nov 07, 2026 02:15 AM	hr	72.0
VIT-005705	Sat Nov 07, 2026 02:15 AM	map	79.0
VIT-005706	Sat Nov 07, 2026 02:15 AM	gcs	15.0
VIT-005655	Sat Nov 07, 2026 10:15 AM	spo2	97.0	room air
VIT-005656	Sat Nov 07, 2026 10:15 AM	rr	17.0
VIT-005707	Sat Nov 07, 2026 10:15 AM	temp_c	37.2
VIT-005708	Sat Nov 07, 2026 10:15 AM	hr	71.0
VIT-005709	Sat Nov 07, 2026 10:15 AM	map	82.0
VIT-005710	Sat Nov 07, 2026 10:15 AM	gcs	15.0
VIT-005657	Sat Nov 07, 2026 06:15 PM	spo2	98.0	room air
VIT-005658	Sat Nov 07, 2026 06:15 PM	rr	14.0
VIT-005711	Sat Nov 07, 2026 06:15 PM	temp_c	36.7
VIT-005712	Sat Nov 07, 2026 06:15 PM	hr	89.0
VIT-005713	Sat Nov 07, 2026 06:15 PM	map	78.0
VIT-005714	Sat Nov 07, 2026 06:15 PM	gcs	15.0
VIT-005659	Sun Nov 08, 2026 02:15 AM	spo2	96.0	room air
VIT-005660	Sun Nov 08, 2026 02:15 AM	rr	14.0
VIT-005715	Sun Nov 08, 2026 02:15 AM	temp_c	36.5
VIT-005716	Sun Nov 08, 2026 02:15 AM	hr	72.0
VIT-005717	Sun Nov 08, 2026 02:15 AM	map	92.0
VIT-005718	Sun Nov 08, 2026 02:15 AM	gcs	15.0
VIT-005661	Sun Nov 08, 2026 10:15 AM	spo2	95.0	room air
VIT-005662	Sun Nov 08, 2026 10:15 AM	rr	14.0
VIT-005719	Sun Nov 08, 2026 10:15 AM	temp_c	36.6
VIT-005720	Sun Nov 08, 2026 10:15 AM	hr	83.0
VIT-005721	Sun Nov 08, 2026 10:15 AM	map	90.0
VIT-005722	Sun Nov 08, 2026 10:15 AM	gcs	15.0
VIT-005663	Sun Nov 08, 2026 06:15 PM	spo2	96.0	room air
VIT-005664	Sun Nov 08, 2026 06:15 PM	rr	16.0
VIT-005723	Sun Nov 08, 2026 06:15 PM	temp_c	36.8
VIT-005724	Sun Nov 08, 2026 06:15 PM	hr	73.0
VIT-005725	Sun Nov 08, 2026 06:15 PM	map	90.0
VIT-005726	Sun Nov 08, 2026 06:15 PM	gcs	15.0
VIT-005665	Mon Nov 09, 2026 02:15 AM	spo2	95.0	room air
VIT-005666	Mon Nov 09, 2026 02:15 AM	rr	15.0
VIT-005727	Mon Nov 09, 2026 02:15 AM	temp_c	37.4
VIT-005728	Mon Nov 09, 2026 02:15 AM	hr	77.0
VIT-005729	Mon Nov 09, 2026 02:15 AM	map	90.0
VIT-005730	Mon Nov 09, 2026 02:15 AM	gcs	15.0
VIT-005667	Mon Nov 09, 2026 10:15 AM	spo2	95.0	room air
VIT-005668	Mon Nov 09, 2026 10:15 AM	rr	20.0
VIT-005731	Mon Nov 09, 2026 10:15 AM	temp_c	36.6
VIT-005732	Mon Nov 09, 2026 10:15 AM	hr	90.0
VIT-005733	Mon Nov 09, 2026 10:15 AM	map	74.0
VIT-005734	Mon Nov 09, 2026 10:15 AM	gcs	15.0
VIT-005669	Mon Nov 09, 2026 06:15 PM	spo2	95.0	room air
VIT-005670	Mon Nov 09, 2026 06:15 PM	rr	14.0
VIT-005735	Mon Nov 09, 2026 06:15 PM	temp_c	37.3
VIT-005736	Mon Nov 09, 2026 06:15 PM	hr	76.0
VIT-005737	Mon Nov 09, 2026 06:15 PM	map	90.0
VIT-005738	Mon Nov 09, 2026 06:15 PM	gcs	15.0
VIT-005671	Tue Nov 10, 2026 02:15 AM	spo2	96.0	room air
VIT-005672	Tue Nov 10, 2026 02:15 AM	rr	17.0
VIT-005739	Tue Nov 10, 2026 02:15 AM	temp_c	37.4
VIT-005740	Tue Nov 10, 2026 02:15 AM	hr	77.0
VIT-005741	Tue Nov 10, 2026 02:15 AM	map	79.0
VIT-005742	Tue Nov 10, 2026 02:15 AM	gcs	15.0
VIT-005673	Tue Nov 10, 2026 10:15 AM	spo2	99.0	room air
VIT-005674	Tue Nov 10, 2026 10:15 AM	rr	16.0
VIT-005743	Tue Nov 10, 2026 10:15 AM	temp_c	36.7
VIT-005744	Tue Nov 10, 2026 10:15 AM	hr	69.0
VIT-005745	Tue Nov 10, 2026 10:15 AM	map	75.0
VIT-005746	Tue Nov 10, 2026 10:15 AM	gcs	15.0

Medications, orders, echo, history (8)

MED-000205 11-04 08:00 furosemide 40 mg IV
MED-000206 11-04 20:00 furosemide 40 mg IV
MED-000207 11-05 08:00 furosemide 40 mg IV
MED-000208 11-05 20:00 furosemide 40 mg IV
MED-000209 11-06 08:00 furosemide 40 mg IV
MED-000210 11-06 20:00 furosemide 40 mg IV
ECH-000026 2026-11-05 echo LVEF 55.0%
HX-000019 history: heart failure with preserved ejection fraction

Notes

History and physical · DOC-000201 · Dr. Elena Nakashima (resident) · Wed Nov 04, 2026 08:55 PM

Source document DOC-000201: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Kenji Galloway   MRN: MRN26501559   Admitted: 2026-11-04 17:55
Service: Cardiology   Attending: Dr. Kenji Stavros

History of present illness: 56-year-old man admitted with chronic diastolic heart failure. 
Past medical history: heart failure with preserved ejection fraction.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Chronic diastolic heart failure: diuresis and daily weights; monitor electrolytes.

Nutrition assessment · DOC-000200 · Vera Pemberton, RD (dietitian) · Thu Nov 05, 2026 07:55 PM

Cited facts from this note (5)

fat_loss: none · cited p. 1, line 7 · confidence 0.90

Show source for fat_loss

… MRN: MRN26501559 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: Kenji Galloway MRN: MRN26501559 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: Kenji Galloway MRN: MRN26501559 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-000200: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Kenji Galloway   MRN: MRN26501559

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-000202 · Dr. Elena Nakashima (resident) · Fri Nov 06, 2026 05:55 PM

Source document DOC-000202: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Kenji Galloway   MRN: MRN26501559   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Chronic diastolic heart failure: continue current management.
2. Hyponatremia: trend sodium.

Resident: Dr. Elena Nakashima   Attending cosign: completed

Discharge summary · DOC-000203 · Dr. Kenji Stavros (attending) · Tue Nov 10, 2026 02:48 PM

Source document DOC-000203: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Kenji Galloway   MRN: MRN26501559
Admitted 2026-11-04; discharged 2026-11-10.

Discharge diagnoses:
- chronic diastolic heart failure
- hyponatremia

Disposition: home with follow-up.