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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-00068: Yusuf Yardley

70F · MRN64016516 · Hospital Medicine · admitted Sat Oct 24, 2026 04:12 PM · discharged Sun Nov 01, 2026 03:00 PM · attending Dr. Wes Merriweather · 164 cm, 57.3 kg

Documented diagnoses (current)

  • Principal: “upper GI bleed” · K92.2 Gastrointestinal hemorrhage, unspecified
  • “malnourished” · E46 Unspecified protein-calorie malnutrition
  • “acute respiratory failure with hypoxia” · J96.01 Acute respiratory failure with hypoxia
  • “anemia” · D64.9 Anemia, unspecified
  • “type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications

Illustrative grouping now: MS-DRG 377 GI hemorrhage with MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 377.

Queries and events

No queries yet.

All rules applied

Every rule's outcome for this encounter (clean results included)
RuleCriteriaFindingOutcome
Acute kidney injury Clinical judgement required Clinical judgement required Clinical judgement required: AKI criteria met only against a presumed baseline (no pre-admission creatinine on file).
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=1.795, t.ratio_s1=1.5, creat_rise_48h=0.02, 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=1.795, t.ratio_s3=3.0, creat_peak=1.4, 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=1.795, 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=True 1
derived: baseline_independent creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started creat_baseline_known=False, creat_rise_48h=0.02, t.rise_abs=0.3, rrt_started=False false
outcome: aki_staged stage >= 1 and baseline_independent stage=1, baseline_independent=False false
outcome: aki_presumed_baseline stage >= 1 stage=1 true
Acute blood loss anaemia Criteria met Specificity gap Documented “anemia” (D64.9); criteria support the more specific Acute blood loss anemia (D62).
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=9.36, 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=3.2, t.drop_major=2.0, prbc_units=2, t.prbc_major=2 true
outcome: met bleeding_documented and anaemic and acute_fall bleeding_documented=True, anaemic=True, acute_fall=True true
Chronic kidney disease Insufficient data No gap Insufficient data: the criteria could not be applied.
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=0, egfr_span_days=unknown, t.chronic_days=90 false
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=unknown, egfr_late=unknown unknown
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=unknown, t.g2=60, egfr_late=unknown unknown
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=unknown, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15 unknown
outcome: duration_not_shown not chronic chronic=False true
Heart failure Clinical judgement required No gap Not documented; only one acute indicator; acuity needs clinical judgement.
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=True 1
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=1, 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=1 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 Criteria met Specificity gap Documented “malnourished” (E46); criteria support the more specific Moderate (non-severe) protein-calorie malnutrition (chronic illness context) (E44.0).
Trace
Rule trace (rule malnutrition v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
StepExpressionInputs and thresholds readResult
derived: a_sev_intake intake_pct <= t.a_sev_intake_pct and intake_days >= t.a_sev_intake_days intake_pct=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=1, muscle_loss=1, fluid=unknown, grip_reduced=unknown 2
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=chronic, a_sev_intake=unknown, a_sev_wt=unknown, fat_loss=1, muscle_loss=1, fluid=unknown, grip_reduced=unknown, c_sev_intake=unknown, 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=chronic, a_sev_intake=unknown, a_mod_intake=unknown, a_sev_wt=unknown, a_mod_wt=unknown, fat_loss=1, muscle_loss=1, fluid=unknown, grip_reduced=unknown, c_sev_intake=unknown, c_mod_intake=unknown, c_sev_wt=unknown, c_mod_wt=unknown 2
outcome: severe n_severe >= 2 n_severe=0 false
outcome: moderate n_moderate >= 2 n_moderate=2 true
Obesity Criteria not met No gap Not documented and not supported.
Trace
Rule trace (rule obesity v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
StepExpressionInputs and thresholds readResult
outcome: not_adult age < t.adult age=70, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=21.3, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=21.3, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=21.3, t.c1=30 false
outcome: not_met bmi < t.c1 bmi=21.3, 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 met No gap Supported as documented (J96.01).
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=86.0, pao2_min_ra=57.0, pf_min=271 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=86.0, t.spo2_ra=88, pao2_min_ra=57.0, t.pao2=60, pf_min=271, t.pf=300 true
derived: distress coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support rr_max=33.0, t.rr_distress=28, wob_increased=unknown, adv_resp_support=False true
outcome: chronic_baseline home_o2 and hypoxemia home_o2=False, hypoxemia=True false
outcome: met hypoxemia and distress hypoxemia=True, distress=True 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=84.0, 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=33.0, t.rr=20, paco2_min_48h=unknown, t.paco2=32 true
derived: sirs_wbc coalesce(wbc_max_48h > t.wbc_hi, false) or coalesce(wbc_min_48h < t.wbc_lo, false) or coalesce(bands_max_48h > t.bands, false) wbc_max_48h=9.58, t.wbc_hi=12, wbc_min_48h=6.68, 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=True, sirs_wbc=False 1
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=271, adv_resp_support=False 2
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=165.0 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=0.44 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=1.4 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=0.78 0
derived: sofa_delta sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline sofa_resp=2, sofa_coag=0, sofa_liver=0, sofa_cardio=0, sofa_cns=0, sofa_renal=1, sofa_renal_baseline=0 3
derived: sepsis3 infection_documented and sofa_delta >= t.sofa_delta infection_documented=False, sofa_delta=3, t.sofa_delta=2 false
derived: sepsis2 infection_documented and sirs_count >= t.sirs_min infection_documented=False, sirs_count=1, 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-002303Sat Oct 24, 2026 04:37 PMpao257.0 mmHg
LAB-002304Sat Oct 24, 2026 04:37 PMfio221.0 %
LAB-002294Sat Oct 24, 2026 05:12 PMcreatinine1.4 mg/dL
LAB-002305Sat Oct 24, 2026 05:12 PMsodium139.0 mmol/L
LAB-002314Sat Oct 24, 2026 05:12 PMhemoglobin12.53 g/dL
LAB-002323Sat Oct 24, 2026 05:12 PMwbc9.58 x10^3/uL
LAB-002324Sat Oct 24, 2026 05:12 PMplatelets165.0 x10^3/uL
LAB-002341Sat Oct 24, 2026 05:12 PMbilirubin0.44 mg/dL
LAB-002295Sun Oct 25, 2026 05:00 AMcreatinine1.16 mg/dL
LAB-002306Sun Oct 25, 2026 05:00 AMsodium137.0 mmol/L
LAB-002315Sun Oct 25, 2026 05:00 AMhemoglobin10.63 g/dL
LAB-002325Sun Oct 25, 2026 05:00 AMwbc6.68 x10^3/uL
LAB-002326Sun Oct 25, 2026 05:00 AMplatelets198.0 x10^3/uL
LAB-002296Mon Oct 26, 2026 05:00 AMcreatinine0.98 mg/dL
LAB-002307Mon Oct 26, 2026 05:00 AMsodium137.0 mmol/L
LAB-002316Mon Oct 26, 2026 05:00 AMhemoglobin9.36 g/dL
LAB-002327Mon Oct 26, 2026 05:00 AMwbc7.88 x10^3/uL
LAB-002328Mon Oct 26, 2026 05:00 AMplatelets296.0 x10^3/uL
LAB-002297Tue Oct 27, 2026 05:00 AMcreatinine0.86 mg/dL
LAB-002308Tue Oct 27, 2026 05:00 AMsodium136.0 mmol/L
LAB-002317Tue Oct 27, 2026 05:00 AMhemoglobin10.16 g/dL
LAB-002329Tue Oct 27, 2026 05:00 AMwbc10.55 x10^3/uL
LAB-002330Tue Oct 27, 2026 05:00 AMplatelets296.0 x10^3/uL
LAB-002298Wed Oct 28, 2026 05:00 AMcreatinine0.8 mg/dL
LAB-002309Wed Oct 28, 2026 05:00 AMsodium142.0 mmol/L
LAB-002318Wed Oct 28, 2026 05:00 AMhemoglobin10.46 g/dL
LAB-002331Wed Oct 28, 2026 05:00 AMwbc6.99 x10^3/uL
LAB-002332Wed Oct 28, 2026 05:00 AMplatelets218.0 x10^3/uL
LAB-002299Thu Oct 29, 2026 05:00 AMcreatinine0.78 mg/dL
LAB-002310Thu Oct 29, 2026 05:00 AMsodium142.0 mmol/L
LAB-002319Thu Oct 29, 2026 05:00 AMhemoglobin10.56 g/dL
LAB-002333Thu Oct 29, 2026 05:00 AMwbc9.88 x10^3/uL
LAB-002334Thu Oct 29, 2026 05:00 AMplatelets234.0 x10^3/uL
LAB-002300Fri Oct 30, 2026 05:00 AMcreatinine0.8 mg/dL
LAB-002311Fri Oct 30, 2026 05:00 AMsodium142.0 mmol/L
LAB-002320Fri Oct 30, 2026 05:00 AMhemoglobin10.56 g/dL
LAB-002335Fri Oct 30, 2026 05:00 AMwbc10.53 x10^3/uL
LAB-002336Fri Oct 30, 2026 05:00 AMplatelets173.0 x10^3/uL
LAB-002301Sat Oct 31, 2026 05:00 AMcreatinine0.79 mg/dL
LAB-002312Sat Oct 31, 2026 05:00 AMsodium138.0 mmol/L
LAB-002321Sat Oct 31, 2026 05:00 AMhemoglobin10.56 g/dL
LAB-002337Sat Oct 31, 2026 05:00 AMwbc6.49 x10^3/uL
LAB-002338Sat Oct 31, 2026 05:00 AMplatelets211.0 x10^3/uL
LAB-002302Sun Nov 01, 2026 05:00 AMcreatinine0.8 mg/dL
LAB-002313Sun Nov 01, 2026 05:00 AMsodium141.0 mmol/L
LAB-002322Sun Nov 01, 2026 05:00 AMhemoglobin10.56 g/dL
LAB-002339Sun Nov 01, 2026 05:00 AMwbc5.69 x10^3/uL
LAB-002340Sun Nov 01, 2026 05:00 AMplatelets231.0 x10^3/uL
Vitals (168)
Vitals
RowWhenKindValueDetail
VIT-006599Sat Oct 24, 2026 04:32 PMspo286.0room air
VIT-006600Sat Oct 24, 2026 04:32 PMrr33.0
VIT-006671Sat Oct 24, 2026 04:32 PMtemp_c36.5
VIT-006672Sat Oct 24, 2026 04:32 PMhr83.0
VIT-006673Sat Oct 24, 2026 04:32 PMmap75.0
VIT-006674Sat Oct 24, 2026 04:32 PMgcs15.0
VIT-006601Sat Oct 24, 2026 04:42 PMo2_lpm5.0nasal cannula
VIT-006602Sun Oct 25, 2026 12:32 AMspo293.0nasal cannula
VIT-006603Sun Oct 25, 2026 12:32 AMrr25.0
VIT-006604Sun Oct 25, 2026 12:32 AMo2_lpm3.0nasal cannula
VIT-006675Sun Oct 25, 2026 12:32 AMtemp_c37.5
VIT-006676Sun Oct 25, 2026 12:32 AMhr77.0
VIT-006677Sun Oct 25, 2026 12:32 AMmap81.0
VIT-006678Sun Oct 25, 2026 12:32 AMgcs15.0
VIT-006605Sun Oct 25, 2026 08:32 AMspo293.0nasal cannula
VIT-006606Sun Oct 25, 2026 08:32 AMrr24.0
VIT-006607Sun Oct 25, 2026 08:32 AMo2_lpm2.0nasal cannula
VIT-006679Sun Oct 25, 2026 08:32 AMtemp_c37.4
VIT-006680Sun Oct 25, 2026 08:32 AMhr84.0
VIT-006681Sun Oct 25, 2026 08:32 AMmap84.0
VIT-006682Sun Oct 25, 2026 08:32 AMgcs15.0
VIT-006608Sun Oct 25, 2026 04:32 PMspo293.0nasal cannula
VIT-006609Sun Oct 25, 2026 04:32 PMrr20.0
VIT-006610Sun Oct 25, 2026 04:32 PMo2_lpm2.0nasal cannula
VIT-006683Sun Oct 25, 2026 04:32 PMtemp_c37.1
VIT-006684Sun Oct 25, 2026 04:32 PMhr78.0
VIT-006685Sun Oct 25, 2026 04:32 PMmap84.0
VIT-006686Sun Oct 25, 2026 04:32 PMgcs15.0
VIT-006611Mon Oct 26, 2026 12:32 AMspo291.0nasal cannula
VIT-006612Mon Oct 26, 2026 12:32 AMrr24.0
VIT-006613Mon Oct 26, 2026 12:32 AMo2_lpm4.0nasal cannula
VIT-006687Mon Oct 26, 2026 12:32 AMtemp_c37.5
VIT-006688Mon Oct 26, 2026 12:32 AMhr78.0
VIT-006689Mon Oct 26, 2026 12:32 AMmap84.0
VIT-006690Mon Oct 26, 2026 12:32 AMgcs15.0
VIT-006614Mon Oct 26, 2026 08:32 AMspo294.0nasal cannula
VIT-006615Mon Oct 26, 2026 08:32 AMrr20.0
VIT-006616Mon Oct 26, 2026 08:32 AMo2_lpm4.0nasal cannula
VIT-006691Mon Oct 26, 2026 08:32 AMtemp_c36.7
VIT-006692Mon Oct 26, 2026 08:32 AMhr77.0
VIT-006693Mon Oct 26, 2026 08:32 AMmap83.0
VIT-006694Mon Oct 26, 2026 08:32 AMgcs15.0
VIT-006617Mon Oct 26, 2026 04:32 PMspo292.0nasal cannula
VIT-006618Mon Oct 26, 2026 04:32 PMrr26.0
VIT-006619Mon Oct 26, 2026 04:32 PMo2_lpm2.0nasal cannula
VIT-006695Mon Oct 26, 2026 04:32 PMtemp_c37.3
VIT-006696Mon Oct 26, 2026 04:32 PMhr88.0
VIT-006697Mon Oct 26, 2026 04:32 PMmap91.0
VIT-006698Mon Oct 26, 2026 04:32 PMgcs15.0
VIT-006620Tue Oct 27, 2026 12:32 AMspo292.0nasal cannula
VIT-006621Tue Oct 27, 2026 12:32 AMrr24.0
VIT-006622Tue Oct 27, 2026 12:32 AMo2_lpm4.0nasal cannula
VIT-006699Tue Oct 27, 2026 12:32 AMtemp_c37.3
VIT-006700Tue Oct 27, 2026 12:32 AMhr74.0
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VIT-006702Tue Oct 27, 2026 12:32 AMgcs15.0
VIT-006623Tue Oct 27, 2026 08:32 AMspo293.0nasal cannula
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VIT-006625Tue Oct 27, 2026 08:32 AMo2_lpm4.0nasal cannula
VIT-006703Tue Oct 27, 2026 08:32 AMtemp_c36.5
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VIT-006706Tue Oct 27, 2026 08:32 AMgcs15.0
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VIT-006628Tue Oct 27, 2026 04:32 PMo2_lpm4.0nasal cannula
VIT-006707Tue Oct 27, 2026 04:32 PMtemp_c37.5
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VIT-006629Wed Oct 28, 2026 12:32 AMspo294.0nasal cannula
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VIT-006631Wed Oct 28, 2026 12:32 AMo2_lpm3.0nasal cannula
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VIT-006632Wed Oct 28, 2026 08:32 AMspo293.0nasal cannula
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VIT-006715Wed Oct 28, 2026 08:32 AMtemp_c36.9
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VIT-006635Wed Oct 28, 2026 04:32 PMspo295.0nasal cannula
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VIT-006637Wed Oct 28, 2026 04:32 PMo2_lpm3.0nasal cannula
VIT-006719Wed Oct 28, 2026 04:32 PMtemp_c36.5
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VIT-006638Thu Oct 29, 2026 12:32 AMspo294.0nasal cannula
VIT-006639Thu Oct 29, 2026 12:32 AMrr20.0
VIT-006640Thu Oct 29, 2026 12:32 AMo2_lpm4.0nasal cannula
VIT-006723Thu Oct 29, 2026 12:32 AMtemp_c37.5
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VIT-006726Thu Oct 29, 2026 12:32 AMgcs15.0
VIT-006641Thu Oct 29, 2026 08:32 AMspo295.0nasal cannula
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VIT-006727Thu Oct 29, 2026 08:32 AMtemp_c36.9
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VIT-006644Thu Oct 29, 2026 04:32 PMspo295.0nasal cannula
VIT-006645Thu Oct 29, 2026 04:32 PMrr20.0
VIT-006646Thu Oct 29, 2026 04:32 PMo2_lpm4.0nasal cannula
VIT-006731Thu Oct 29, 2026 04:32 PMtemp_c37.1
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VIT-006647Fri Oct 30, 2026 12:32 AMspo293.0nasal cannula
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VIT-006651Fri Oct 30, 2026 08:32 AMrr25.0
VIT-006652Fri Oct 30, 2026 08:32 AMo2_lpm3.0nasal cannula
VIT-006739Fri Oct 30, 2026 08:32 AMtemp_c37.4
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VIT-006653Fri Oct 30, 2026 04:32 PMspo292.0nasal cannula
VIT-006654Fri Oct 30, 2026 04:32 PMrr22.0
VIT-006655Fri Oct 30, 2026 04:32 PMo2_lpm2.0nasal cannula
VIT-006743Fri Oct 30, 2026 04:32 PMtemp_c36.6
VIT-006744Fri Oct 30, 2026 04:32 PMhr89.0
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VIT-006746Fri Oct 30, 2026 04:32 PMgcs15.0
VIT-006656Sat Oct 31, 2026 12:32 AMspo294.0nasal cannula
VIT-006657Sat Oct 31, 2026 12:32 AMrr22.0
VIT-006658Sat Oct 31, 2026 12:32 AMo2_lpm2.0nasal cannula
VIT-006747Sat Oct 31, 2026 12:32 AMtemp_c36.6
VIT-006748Sat Oct 31, 2026 12:32 AMhr85.0
VIT-006749Sat Oct 31, 2026 12:32 AMmap90.0
VIT-006750Sat Oct 31, 2026 12:32 AMgcs15.0
VIT-006659Sat Oct 31, 2026 08:32 AMspo295.0nasal cannula
VIT-006660Sat Oct 31, 2026 08:32 AMrr26.0
VIT-006661Sat Oct 31, 2026 08:32 AMo2_lpm4.0nasal cannula
VIT-006751Sat Oct 31, 2026 08:32 AMtemp_c36.8
VIT-006752Sat Oct 31, 2026 08:32 AMhr69.0
VIT-006753Sat Oct 31, 2026 08:32 AMmap85.0
VIT-006754Sat Oct 31, 2026 08:32 AMgcs15.0
VIT-006662Sat Oct 31, 2026 04:32 PMspo291.0nasal cannula
VIT-006663Sat Oct 31, 2026 04:32 PMrr20.0
VIT-006664Sat Oct 31, 2026 04:32 PMo2_lpm3.0nasal cannula
VIT-006755Sat Oct 31, 2026 04:32 PMtemp_c37.4
VIT-006756Sat Oct 31, 2026 04:32 PMhr84.0
VIT-006757Sat Oct 31, 2026 04:32 PMmap81.0
VIT-006758Sat Oct 31, 2026 04:32 PMgcs15.0
VIT-006665Sun Nov 01, 2026 12:32 AMspo291.0nasal cannula
VIT-006666Sun Nov 01, 2026 12:32 AMrr21.0
VIT-006667Sun Nov 01, 2026 12:32 AMo2_lpm2.0nasal cannula
VIT-006759Sun Nov 01, 2026 12:32 AMtemp_c36.8
VIT-006760Sun Nov 01, 2026 12:32 AMhr80.0
VIT-006761Sun Nov 01, 2026 12:32 AMmap81.0
VIT-006762Sun Nov 01, 2026 12:32 AMgcs15.0
VIT-006668Sun Nov 01, 2026 08:32 AMspo294.0nasal cannula
VIT-006669Sun Nov 01, 2026 08:32 AMrr22.0
VIT-006670Sun Nov 01, 2026 08:32 AMo2_lpm3.0nasal cannula
VIT-006763Sun Nov 01, 2026 08:32 AMtemp_c37.0
VIT-006764Sun Nov 01, 2026 08:32 AMhr86.0
VIT-006765Sun Nov 01, 2026 08:32 AMmap83.0
VIT-006766Sun Nov 01, 2026 08:32 AMgcs15.0
Medications, orders, echo, history (1)

Notes

History and physical · DOC-000234 · Dr. Wes Merriweather (attending) · Sat Oct 24, 2026 07:12 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. Wes Merriweather History of present illness: 70-year-old woman admitted with upper GI bleed. Presented after two days of hematemesis; GI consulted for endoscopy. Past medical history: type 2 diabetes. Review of systems otherwise negative. Exam: Lungs: labored respirations. Assessment and pla …
Source document DOC-000234: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Yusuf Yardley   MRN: MRN64016516   Admitted: 2026-10-24 16:12
Service: Hospital Medicine   Attending: Dr. Wes Merriweather

History of present illness: 70-year-old woman admitted with upper GI bleed. Presented after two days of hematemesis; GI consulted for endoscopy.
Past medical history: type 2 diabetes.
Review of systems otherwise negative.
Exam: Lungs: labored respirations.
Assessment and plan:
1. Upper GI bleed: PPI, GI following.

Nutrition assessment · DOC-000233 · Vera Pemberton, RD (dietitian) · Sun Oct 25, 2026 09:12 PM

Cited facts from this note (3)
fat_loss
mild · cited p. 1, line 3 · confidence 0.90
Show source for fat_loss
… in the setting of chronic illness. Eating about half of meals for the past 5 weeks. Weight 57.3 kg, down from 63.6 kg three months ago. Mild temporal wasting; mild fat loss at the triceps. No edema. Hand grip not assessed. Plan: oral supplement twice daily; recheck weight weekly.
muscle_loss
mild · cited p. 1, line 3 · confidence 0.90
Show source for muscle_loss
… follow-up note Pt seen in the setting of chronic illness. Eating about half of meals for the past 5 weeks. Weight 57.3 kg, down from 63.6 kg three months ago. Mild temporal wasting; mild fat loss at the triceps. No edema. Hand grip not assessed. Plan: oral supplement twice daily; recheck weight weekly.
nutrition_context
chronic · cited p. 1, line 3 · confidence 0.80
Show source for nutrition_context
RD follow-up note Pt seen in the setting of chronic illness. Eating about half of meals for the past 5 weeks. Weight 57.3 kg, down from 63.6 kg three months ago. Mild temporal wasting; mild fat loss at the triceps. No e …
Source document DOC-000233: Nutrition assessment (synthetic)
RD follow-up note

Pt seen in the setting of chronic illness. Eating about half of meals for the past 5 weeks. Weight 57.3 kg, down from 63.6 kg three months ago. Mild temporal wasting; mild fat loss at the triceps. No edema. Hand grip not assessed.
Plan: oral supplement twice daily; recheck weight weekly.

Progress note · DOC-000235 · Dr. Wes Merriweather (attending) · Mon Oct 26, 2026 06:12 PM

Source document DOC-000235: Progress note (synthetic)
PROGRESS NOTE (Attending)
Patient: Yusuf Yardley   MRN: MRN64016516   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. Malnourished: dietitian following.
3. Acute respiratory failure with hypoxia: supplemental oxygen, wean as tolerated.
4. Anemia: trend hemoglobin.

Attending: Dr. Wes Merriweather

Discharge summary · DOC-000236 · Dr. Wes Merriweather (attending) · Sun Nov 01, 2026 03:00 PM

Source document DOC-000236: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Yusuf Yardley   MRN: MRN64016516
Admitted 2026-10-24; discharged 2026-11-01.

Discharge diagnoses:
- upper GI bleed
- malnourished
- acute respiratory failure with hypoxia
- anemia
- type 2 diabetes

Disposition: home with follow-up.