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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-00069: Vera Fairbanks

49F · MRN32351809 · Cardiology · admitted Mon Nov 02, 2026 09:38 PM · discharged Mon Nov 09, 2026 10:28 AM · attending Dr. Isaac Abernath · 167 cm, 71.9 kg

Documented diagnoses (current)

  • “acute renal insufficiency” · N28.9 Disorder of kidney and ureter, unspecified (renal insufficiency)
  • Principal: “congestive heart failure” · I50.9 Heart failure, unspecified
  • “type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications
  • “hyperlipidemia” · E78.5 Hyperlipidemia, unspecified

Illustrative grouping now: MS-DRG 293 Heart failure and shock without CC/MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 292.

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 Documented “acute renal insufficiency” (N28.9); criteria support the more specific Acute kidney injury (KDIGO stage 1) (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=1.782, t.ratio_s1=1.5, creat_rise_48h=0.34, 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=1.782, t.ratio_s3=3.0, creat_peak=1.55, 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=1.782, 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=True, creat_rise_48h=0.34, t.rise_abs=0.3, rrt_started=False true
outcome: aki_staged stage >= 1 and baseline_independent stage=1, 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=13.21, 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=13.21, 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=255, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=85.1, egfr_late=81.6 85.1
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=85.1, t.g2=60, egfr_late=81.6 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=85.1, 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=85.1, egfr_late=81.6, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=85.1, t.g2=60 true
Heart failure Criteria met Specificity gap Documented “congestive heart failure” (I50.9); 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)
StepExpressionInputs and thresholds readResult
derived: np_elevated coalesce(bnp_max >= t.bnp, false) or coalesce(ntprobnp_max >= t.ntprobnp, false) bnp_max=1606.0, 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=63.0, 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=63.0, 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 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 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=49, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=25.8, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=25.8, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=25.8, t.c1=30 false
outcome: not_met bmi < t.c1 bmi=25.8, 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=87.0, 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=19.0, 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=9.46, t.wbc_hi=12, wbc_min_48h=6.82, 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=269.0 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=0.84 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=1.55 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=0.87 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 (44)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-002342Tue Nov 11, 2025 09:15 AMcreatinine0.84 mg/dL
LAB-002343Sat Jul 25, 2026 10:05 AMcreatinine0.87 mg/dL
LAB-002344Mon Nov 02, 2026 10:38 PMcreatinine1.21 mg/dL
LAB-002352Mon Nov 02, 2026 10:38 PMbnp1606.0 pg/mL
LAB-002353Mon Nov 02, 2026 10:38 PMsodium138.0 mmol/L
LAB-002361Mon Nov 02, 2026 10:38 PMhemoglobin13.35 g/dL
LAB-002369Mon Nov 02, 2026 10:38 PMwbc8.25 x10^3/uL
LAB-002370Mon Nov 02, 2026 10:38 PMplatelets308.0 x10^3/uL
LAB-002385Mon Nov 02, 2026 10:38 PMbilirubin0.84 mg/dL
LAB-002345Tue Nov 03, 2026 05:00 AMcreatinine1.55 mg/dL
LAB-002354Tue Nov 03, 2026 05:00 AMsodium142.0 mmol/L
LAB-002362Tue Nov 03, 2026 05:00 AMhemoglobin13.52 g/dL
LAB-002371Tue Nov 03, 2026 05:00 AMwbc9.46 x10^3/uL
LAB-002372Tue Nov 03, 2026 05:00 AMplatelets269.0 x10^3/uL
LAB-002346Wed Nov 04, 2026 05:00 AMcreatinine1.4 mg/dL
LAB-002355Wed Nov 04, 2026 05:00 AMsodium142.0 mmol/L
LAB-002363Wed Nov 04, 2026 05:00 AMhemoglobin13.59 g/dL
LAB-002373Wed Nov 04, 2026 05:00 AMwbc6.82 x10^3/uL
LAB-002374Wed Nov 04, 2026 05:00 AMplatelets290.0 x10^3/uL
LAB-002347Thu Nov 05, 2026 05:00 AMcreatinine1.16 mg/dL
LAB-002356Thu Nov 05, 2026 05:00 AMsodium136.0 mmol/L
LAB-002364Thu Nov 05, 2026 05:00 AMhemoglobin13.74 g/dL
LAB-002375Thu Nov 05, 2026 05:00 AMwbc10.28 x10^3/uL
LAB-002376Thu Nov 05, 2026 05:00 AMplatelets243.0 x10^3/uL
LAB-002348Fri Nov 06, 2026 05:00 AMcreatinine0.96 mg/dL
LAB-002357Fri Nov 06, 2026 05:00 AMsodium141.0 mmol/L
LAB-002365Fri Nov 06, 2026 05:00 AMhemoglobin13.62 g/dL
LAB-002377Fri Nov 06, 2026 05:00 AMwbc10.95 x10^3/uL
LAB-002378Fri Nov 06, 2026 05:00 AMplatelets301.0 x10^3/uL
LAB-002349Sat Nov 07, 2026 05:00 AMcreatinine0.91 mg/dL
LAB-002358Sat Nov 07, 2026 05:00 AMsodium137.0 mmol/L
LAB-002366Sat Nov 07, 2026 05:00 AMhemoglobin13.21 g/dL
LAB-002379Sat Nov 07, 2026 05:00 AMwbc7.38 x10^3/uL
LAB-002380Sat Nov 07, 2026 05:00 AMplatelets197.0 x10^3/uL
LAB-002350Sun Nov 08, 2026 05:00 AMcreatinine0.91 mg/dL
LAB-002359Sun Nov 08, 2026 05:00 AMsodium137.0 mmol/L
LAB-002367Sun Nov 08, 2026 05:00 AMhemoglobin13.71 g/dL
LAB-002381Sun Nov 08, 2026 05:00 AMwbc5.99 x10^3/uL
LAB-002382Sun Nov 08, 2026 05:00 AMplatelets178.0 x10^3/uL
LAB-002351Mon Nov 09, 2026 05:00 AMcreatinine0.91 mg/dL
LAB-002360Mon Nov 09, 2026 05:00 AMsodium142.0 mmol/L
LAB-002368Mon Nov 09, 2026 05:00 AMhemoglobin13.76 g/dL
LAB-002383Mon Nov 09, 2026 05:00 AMwbc7.12 x10^3/uL
LAB-002384Mon Nov 09, 2026 05:00 AMplatelets179.0 x10^3/uL
Vitals (120)
Vitals
RowWhenKindValueDetail
VIT-006767Mon Nov 02, 2026 09:58 PMspo298.0room air
VIT-006768Mon Nov 02, 2026 09:58 PMrr15.0
VIT-006807Mon Nov 02, 2026 09:58 PMtemp_c37.5
VIT-006808Mon Nov 02, 2026 09:58 PMhr87.0
VIT-006809Mon Nov 02, 2026 09:58 PMmap83.0
VIT-006810Mon Nov 02, 2026 09:58 PMgcs15.0
VIT-006769Tue Nov 03, 2026 05:58 AMspo297.0room air
VIT-006770Tue Nov 03, 2026 05:58 AMrr19.0
VIT-006811Tue Nov 03, 2026 05:58 AMtemp_c36.7
VIT-006812Tue Nov 03, 2026 05:58 AMhr86.0
VIT-006813Tue Nov 03, 2026 05:58 AMmap81.0
VIT-006814Tue Nov 03, 2026 05:58 AMgcs15.0
VIT-006771Tue Nov 03, 2026 01:58 PMspo296.0room air
VIT-006772Tue Nov 03, 2026 01:58 PMrr14.0
VIT-006815Tue Nov 03, 2026 01:58 PMtemp_c36.6
VIT-006816Tue Nov 03, 2026 01:58 PMhr70.0
VIT-006817Tue Nov 03, 2026 01:58 PMmap84.0
VIT-006818Tue Nov 03, 2026 01:58 PMgcs15.0
VIT-006773Tue Nov 03, 2026 09:58 PMspo294.0room air
VIT-006774Tue Nov 03, 2026 09:58 PMrr15.0
VIT-006819Tue Nov 03, 2026 09:58 PMtemp_c37.4
VIT-006820Tue Nov 03, 2026 09:58 PMhr84.0
VIT-006821Tue Nov 03, 2026 09:58 PMmap87.0
VIT-006822Tue Nov 03, 2026 09:58 PMgcs15.0
VIT-006775Wed Nov 04, 2026 05:58 AMspo296.0room air
VIT-006776Wed Nov 04, 2026 05:58 AMrr14.0
VIT-006823Wed Nov 04, 2026 05:58 AMtemp_c36.7
VIT-006824Wed Nov 04, 2026 05:58 AMhr75.0
VIT-006825Wed Nov 04, 2026 05:58 AMmap87.0
VIT-006826Wed Nov 04, 2026 05:58 AMgcs15.0
VIT-006777Wed Nov 04, 2026 01:58 PMspo297.0room air
VIT-006778Wed Nov 04, 2026 01:58 PMrr17.0
VIT-006827Wed Nov 04, 2026 01:58 PMtemp_c36.6
VIT-006828Wed Nov 04, 2026 01:58 PMhr69.0
VIT-006829Wed Nov 04, 2026 01:58 PMmap75.0
VIT-006830Wed Nov 04, 2026 01:58 PMgcs15.0
VIT-006779Wed Nov 04, 2026 09:58 PMspo296.0room air
VIT-006780Wed Nov 04, 2026 09:58 PMrr20.0
VIT-006831Wed Nov 04, 2026 09:58 PMtemp_c36.7
VIT-006832Wed Nov 04, 2026 09:58 PMhr87.0
VIT-006833Wed Nov 04, 2026 09:58 PMmap82.0
VIT-006834Wed Nov 04, 2026 09:58 PMgcs15.0
VIT-006781Thu Nov 05, 2026 05:58 AMspo296.0room air
VIT-006782Thu Nov 05, 2026 05:58 AMrr14.0
VIT-006835Thu Nov 05, 2026 05:58 AMtemp_c37.2
VIT-006836Thu Nov 05, 2026 05:58 AMhr76.0
VIT-006837Thu Nov 05, 2026 05:58 AMmap87.0
VIT-006838Thu Nov 05, 2026 05:58 AMgcs15.0
VIT-006783Thu Nov 05, 2026 01:58 PMspo294.0room air
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VIT-006839Thu Nov 05, 2026 01:58 PMtemp_c36.7
VIT-006840Thu Nov 05, 2026 01:58 PMhr74.0
VIT-006841Thu Nov 05, 2026 01:58 PMmap91.0
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VIT-006785Thu Nov 05, 2026 09:58 PMspo296.0room air
VIT-006786Thu Nov 05, 2026 09:58 PMrr19.0
VIT-006843Thu Nov 05, 2026 09:58 PMtemp_c36.9
VIT-006844Thu Nov 05, 2026 09:58 PMhr79.0
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VIT-006787Fri Nov 06, 2026 05:58 AMspo294.0room air
VIT-006788Fri Nov 06, 2026 05:58 AMrr17.0
VIT-006847Fri Nov 06, 2026 05:58 AMtemp_c37.2
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VIT-006789Fri Nov 06, 2026 01:58 PMspo299.0room air
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VIT-006797Sat Nov 07, 2026 09:58 PMspo295.0room air
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VIT-006882Sun Nov 08, 2026 09:58 PMgcs15.0
VIT-006805Mon Nov 09, 2026 05:58 AMspo296.0room air
VIT-006806Mon Nov 09, 2026 05:58 AMrr19.0
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VIT-006884Mon Nov 09, 2026 05:58 AMhr91.0
VIT-006885Mon Nov 09, 2026 05:58 AMmap89.0
VIT-006886Mon Nov 09, 2026 05:58 AMgcs15.0
Medications, orders, echo, history (8)

Notes

History and physical · DOC-000237 · Dr. Isaac Abernath (attending) · Tue Nov 03, 2026 12:38 AM

Source document DOC-000237: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Vera Fairbanks   MRN: MRN32351809   Admitted: 2026-11-02 21:38
Service: Cardiology   Attending: Dr. Isaac Abernath

History of present illness: 49-year-old woman admitted with congestive heart failure. 
Past medical history: heart failure with preserved ejection fraction, type 2 diabetes, hyperlipidemia.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Congestive heart failure: diuresis and daily weights; monitor electrolytes.

Progress note · DOC-000238 · Dr. Isaac Abernath (attending) · Wed Nov 04, 2026 09:38 PM

Source document DOC-000238: Progress note (synthetic)
PROGRESS NOTE (Attending)
Patient: Vera Fairbanks   MRN: MRN32351809   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Congestive heart failure: continue current management.
2. Acute renal insufficiency: trend creatinine, avoid nephrotoxins.

Attending: Dr. Isaac Abernath

Discharge summary · DOC-000239 · Dr. Isaac Abernath (attending) · Mon Nov 09, 2026 10:28 AM

Source document DOC-000239: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Vera Fairbanks   MRN: MRN32351809
Admitted 2026-11-02; discharged 2026-11-09.

Discharge diagnoses:
- acute renal insufficiency
- congestive heart failure
- type 2 diabetes
- hyperlipidemia

Disposition: home with follow-up.