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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-00072: Hana Upfield

81M · MRN76796753 · Hospital Medicine · admitted Thu Oct 29, 2026 09:52 AM · discharged Thu Nov 05, 2026 04:23 PM · attending Dr. Odette Galloway · resident Dr. Elena Nakashima · 178 cm, 99.4 kg

Documented diagnoses (current)

  • Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
  • “chronic kidney disease” · N18.9 Chronic kidney disease, unspecified
  • “acute kidney injury” · N17.9 Acute kidney failure, unspecified
  • “anemia” · D64.9 Anemia, unspecified
  • “type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications

Illustrative grouping now: MS-DRG 194 Simple pneumonia and pleurisy with CC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 194.

Queries and events

No queries yet.

All rules applied

Every rule's outcome for this encounter (clean results included)
RuleCriteriaFindingOutcome
Acute kidney injury Criteria met No gap Supported as documented (N17.9).
Trace
Rule trace (rule aki v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
StepExpressionInputs and thresholds readResult
derived: meets_definition creat_ratio >= t.ratio_s1 or creat_rise_48h >= t.rise_abs or coalesce(uo_hours_lt_0_5 >= t.uo_s1_h, false) creat_ratio=3.549, t.ratio_s1=1.5, creat_rise_48h=1.35, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, t.uo_s1_h=6 true
derived: stage3 meets_definition and (creat_ratio >= t.ratio_s3 or creat_peak >= t.scr_s3 or rrt_started or coalesce(uo_hours_lt_0_3 >= t.uo_s3_h, false) or coalesce(anuria_hours >= t.anuria_h, false)) meets_definition=True, creat_ratio=3.549, t.ratio_s3=3.0, creat_peak=6.14, t.scr_s3=4.0, rrt_started=False, uo_hours_lt_0_3=unknown, t.uo_s3_h=24, anuria_hours=unknown, t.anuria_h=12 true
derived: stage2 creat_ratio >= t.ratio_s2 or coalesce(uo_hours_lt_0_5 >= t.uo_s2_h, false) creat_ratio=3.549, t.ratio_s2=2.0, uo_hours_lt_0_5=unknown, t.uo_s2_h=12 true
derived: stage case(stage3, 3, stage2, 2, meets_definition, 1, 0) stage3=True, stage2=True, meets_definition=True 3
derived: baseline_independent creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started creat_baseline_known=True, creat_rise_48h=1.35, t.rise_abs=0.3, rrt_started=False true
outcome: aki_staged stage >= 1 and baseline_independent stage=3, baseline_independent=True true
Acute blood loss anaemia Criteria 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=M, hgb_nadir=9.96, 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=3.5, 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 Criteria met Specificity gap Documented “chronic kidney disease” (N18.9); criteria support the more specific Chronic kidney disease stage 3b (N18.32).
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=281, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=39.2, egfr_late=39.2 39.2
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=39.2, t.g2=60, egfr_late=39.2 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=39.2, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15 G3b
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=39.2, egfr_late=39.2, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=39.2, t.g2=60 false
outcome: g3a category == 'G3a' category=G3b false
outcome: g3b category == 'G3b' category=G3b 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 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 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 Criteria support Obesity, class 1 (E66.811); no corresponding diagnosis is documented.
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=81, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=31.4, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=31.4, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=31.4, 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 met No gap Criteria support Sepsis (Sepsis-3); not documented (this rule does not prompt for an undocumented diagnosis).
Trace
Rule trace (rule sepsis v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
StepExpressionInputs and thresholds readResult
derived: sirs_temp coalesce(temp_max_48h > t.t_hi, false) or coalesce(temp_min_48h < t.t_lo, false) temp_max_48h=37.4, t.t_hi=38, temp_min_48h=36.6, t.t_lo=36 false
derived: sirs_hr coalesce(hr_max_48h > t.hr, false) hr_max_48h=86.0, t.hr=90 false
derived: sirs_rr coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false) rr_max_48h=20.0, t.rr=20, paco2_min_48h=unknown, t.paco2=32 false
derived: sirs_wbc coalesce(wbc_max_48h > t.wbc_hi, false) or coalesce(wbc_min_48h < t.wbc_lo, false) or coalesce(bands_max_48h > t.bands, false) wbc_max_48h=9.4, t.wbc_hi=12, wbc_min_48h=7.09, 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=172.0 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=0.64 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=76.0 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=6.14 4
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=1.73 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=4, sofa_renal_baseline=1 3
derived: sepsis3 infection_documented and sofa_delta >= t.sofa_delta infection_documented=True, sofa_delta=3, t.sofa_delta=2 true
derived: sepsis2 infection_documented and sirs_count >= t.sirs_min infection_documented=True, 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=True, norepi_max_48h=0.0, lactate_max_48h=unknown, t.lactate=2 false
outcome: no_infection not infection_documented infection_documented=True false
outcome: septic_shock shock shock=False false
outcome: both sepsis3 and sepsis2 sepsis3=True, sepsis2=False false
outcome: sepsis3_only sepsis3 sepsis3=True true

Structured data

Labs (43)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-002449Fri Oct 03, 2025 09:15 AMcreatinine1.73 mg/dL
LAB-002450Sat Jul 11, 2026 10:05 AMcreatinine1.73 mg/dL
LAB-002451Thu Oct 29, 2026 10:52 AMcreatinine4.79 mg/dL
LAB-002459Thu Oct 29, 2026 10:52 AMsodium141.0 mmol/L
LAB-002467Thu Oct 29, 2026 10:52 AMhemoglobin13.47 g/dL
LAB-002475Thu Oct 29, 2026 10:52 AMwbc7.09 x10^3/uL
LAB-002476Thu Oct 29, 2026 10:52 AMplatelets199.0 x10^3/uL
LAB-002491Thu Oct 29, 2026 10:52 AMbilirubin0.64 mg/dL
LAB-002452Fri Oct 30, 2026 05:00 AMcreatinine6.14 mg/dL
LAB-002460Fri Oct 30, 2026 05:00 AMsodium141.0 mmol/L
LAB-002468Fri Oct 30, 2026 05:00 AMhemoglobin11.37 g/dL
LAB-002477Fri Oct 30, 2026 05:00 AMwbc7.12 x10^3/uL
LAB-002478Fri Oct 30, 2026 05:00 AMplatelets172.0 x10^3/uL
LAB-002453Sat Oct 31, 2026 05:00 AMcreatinine5.53 mg/dL
LAB-002461Sat Oct 31, 2026 05:00 AMsodium142.0 mmol/L
LAB-002469Sat Oct 31, 2026 05:00 AMhemoglobin9.96 g/dL
LAB-002479Sat Oct 31, 2026 05:00 AMwbc9.4 x10^3/uL
LAB-002480Sat Oct 31, 2026 05:00 AMplatelets265.0 x10^3/uL
LAB-002454Sun Nov 01, 2026 05:00 AMcreatinine4.61 mg/dL
LAB-002462Sun Nov 01, 2026 05:00 AMsodium138.0 mmol/L
LAB-002470Sun Nov 01, 2026 05:00 AMhemoglobin10.76 g/dL
LAB-002481Sun Nov 01, 2026 05:00 AMwbc9.94 x10^3/uL
LAB-002482Sun Nov 01, 2026 05:00 AMplatelets285.0 x10^3/uL
LAB-002455Mon Nov 02, 2026 05:00 AMcreatinine3.81 mg/dL
LAB-002463Mon Nov 02, 2026 05:00 AMsodium142.0 mmol/L
LAB-002471Mon Nov 02, 2026 05:00 AMhemoglobin11.06 g/dL
LAB-002483Mon Nov 02, 2026 05:00 AMwbc10.03 x10^3/uL
LAB-002484Mon Nov 02, 2026 05:00 AMplatelets202.0 x10^3/uL
LAB-002456Tue Nov 03, 2026 05:00 AMcreatinine3.38 mg/dL
LAB-002464Tue Nov 03, 2026 05:00 AMsodium138.0 mmol/L
LAB-002472Tue Nov 03, 2026 05:00 AMhemoglobin11.16 g/dL
LAB-002485Tue Nov 03, 2026 05:00 AMwbc9.63 x10^3/uL
LAB-002486Tue Nov 03, 2026 05:00 AMplatelets299.0 x10^3/uL
LAB-002457Wed Nov 04, 2026 05:00 AMcreatinine3.07 mg/dL
LAB-002465Wed Nov 04, 2026 05:00 AMsodium136.0 mmol/L
LAB-002473Wed Nov 04, 2026 05:00 AMhemoglobin11.16 g/dL
LAB-002487Wed Nov 04, 2026 05:00 AMwbc7.0 x10^3/uL
LAB-002488Wed Nov 04, 2026 05:00 AMplatelets306.0 x10^3/uL
LAB-002458Thu Nov 05, 2026 05:00 AMcreatinine2.95 mg/dL
LAB-002466Thu Nov 05, 2026 05:00 AMsodium141.0 mmol/L
LAB-002474Thu Nov 05, 2026 05:00 AMhemoglobin11.16 g/dL
LAB-002489Thu Nov 05, 2026 05:00 AMwbc8.25 x10^3/uL
LAB-002490Thu Nov 05, 2026 05:00 AMplatelets210.0 x10^3/uL
Vitals (132)
Vitals
RowWhenKindValueDetail
VIT-007072Thu Oct 29, 2026 10:12 AMspo298.0room air
VIT-007073Thu Oct 29, 2026 10:12 AMrr15.0
VIT-007116Thu Oct 29, 2026 10:12 AMtemp_c37.1
VIT-007117Thu Oct 29, 2026 10:12 AMhr82.0
VIT-007118Thu Oct 29, 2026 10:12 AMmap82.0
VIT-007119Thu Oct 29, 2026 10:12 AMgcs15.0
VIT-007074Thu Oct 29, 2026 06:12 PMspo297.0room air
VIT-007075Thu Oct 29, 2026 06:12 PMrr17.0
VIT-007120Thu Oct 29, 2026 06:12 PMtemp_c37.2
VIT-007121Thu Oct 29, 2026 06:12 PMhr79.0
VIT-007122Thu Oct 29, 2026 06:12 PMmap88.0
VIT-007123Thu Oct 29, 2026 06:12 PMgcs15.0
VIT-007076Fri Oct 30, 2026 02:12 AMspo299.0room air
VIT-007077Fri Oct 30, 2026 02:12 AMrr15.0
VIT-007124Fri Oct 30, 2026 02:12 AMtemp_c37.4
VIT-007125Fri Oct 30, 2026 02:12 AMhr69.0
VIT-007126Fri Oct 30, 2026 02:12 AMmap85.0
VIT-007127Fri Oct 30, 2026 02:12 AMgcs15.0
VIT-007078Fri Oct 30, 2026 10:12 AMspo294.0room air
VIT-007079Fri Oct 30, 2026 10:12 AMrr20.0
VIT-007128Fri Oct 30, 2026 10:12 AMtemp_c36.6
VIT-007129Fri Oct 30, 2026 10:12 AMhr70.0
VIT-007130Fri Oct 30, 2026 10:12 AMmap76.0
VIT-007131Fri Oct 30, 2026 10:12 AMgcs15.0
VIT-007080Fri Oct 30, 2026 06:12 PMspo299.0room air
VIT-007081Fri Oct 30, 2026 06:12 PMrr15.0
VIT-007132Fri Oct 30, 2026 06:12 PMtemp_c37.1
VIT-007133Fri Oct 30, 2026 06:12 PMhr84.0
VIT-007134Fri Oct 30, 2026 06:12 PMmap85.0
VIT-007135Fri Oct 30, 2026 06:12 PMgcs15.0
VIT-007082Sat Oct 31, 2026 02:12 AMspo295.0room air
VIT-007083Sat Oct 31, 2026 02:12 AMrr15.0
VIT-007136Sat Oct 31, 2026 02:12 AMtemp_c36.7
VIT-007137Sat Oct 31, 2026 02:12 AMhr86.0
VIT-007138Sat Oct 31, 2026 02:12 AMmap81.0
VIT-007139Sat Oct 31, 2026 02:12 AMgcs15.0
VIT-007084Sat Oct 31, 2026 10:12 AMspo295.0room air
VIT-007085Sat Oct 31, 2026 10:12 AMrr15.0
VIT-007140Sat Oct 31, 2026 10:12 AMtemp_c37.1
VIT-007141Sat Oct 31, 2026 10:12 AMhr82.0
VIT-007142Sat Oct 31, 2026 10:12 AMmap79.0
VIT-007143Sat Oct 31, 2026 10:12 AMgcs15.0
VIT-007086Sat Oct 31, 2026 06:12 PMspo298.0room air
VIT-007087Sat Oct 31, 2026 06:12 PMrr17.0
VIT-007144Sat Oct 31, 2026 06:12 PMtemp_c37.1
VIT-007145Sat Oct 31, 2026 06:12 PMhr80.0
VIT-007146Sat Oct 31, 2026 06:12 PMmap74.0
VIT-007147Sat Oct 31, 2026 06:12 PMgcs15.0
VIT-007088Sun Nov 01, 2026 02:12 AMspo294.0room air
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Medications, orders, echo, history (5)

Notes

History and physical · DOC-000248 · Dr. Elena Nakashima (resident) · Thu Oct 29, 2026 12:52 PM

Cited facts from this note (2)
bleeding_source
bleeding from the surgical drain · cited p. 1, line 5 · confidence 0.85
Show source for bleeding_source
… dmitted with community-acquired pneumonia. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Hospital course complicated by bleeding from the surgical drain. Past medical history: type 2 diabetes. Review of systems otherwise negative. Exam: Lungs: scattered crackles at the bases, no distress. Assessment and plan: 1 …
infection_source
multifocal pneumonia · cited p. 1, line 5 · confidence 0.85
Show source for infection_source
… : Hospital Medicine Attending: Dr. Odette Galloway History of present illness: 81-year-old man admitted with community-acquired pneumonia. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Hospital course complicated by bleeding from the surgical drain. Past medical history: type 2 diabetes. Review o …
Source document DOC-000248: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Hana Upfield   MRN: MRN76796753   Admitted: 2026-10-29 09:52
Service: Hospital Medicine   Attending: Dr. Odette Galloway

History of present illness: 81-year-old man admitted with community-acquired pneumonia. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Hospital course complicated by bleeding from the surgical drain.
Past medical history: type 2 diabetes.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.
2. Chronic kidney disease: renally dose medications.

Nutrition assessment · DOC-000247 · Viggo Ravensworth, RD (dietitian) · Fri Oct 30, 2026 03:52 PM

Cited facts from this note (5)
fat_loss
none · cited p. 1, line 7 · confidence 0.90
Show source for fat_loss
… MRN: MRN76796753 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: Hana Upfield MRN: MRN76796753 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: Hana Upfield MRN: MRN76796753 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-000247: Nutrition assessment (synthetic)
NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Hana Upfield   MRN: MRN76796753

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-000249 · Dr. Elena Nakashima (resident) · Sat Oct 31, 2026 01:52 PM

Source document DOC-000249: Progress note (synthetic)
PROGRESS NOTE (Resident)
Patient: Hana Upfield   MRN: MRN76796753   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Community-acquired pneumonia: continue current management.
2. Acute kidney injury: trend creatinine, hold nephrotoxins, strict intake and output.
3. Anemia: trend hemoglobin.

Resident: Dr. Elena Nakashima   Attending cosign: completed

Discharge summary · DOC-000250 · Dr. Odette Galloway (attending) · Thu Nov 05, 2026 04:23 PM

Source document DOC-000250: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Hana Upfield   MRN: MRN76796753
Admitted 2026-10-29; discharged 2026-11-05.

Discharge diagnoses:
- community-acquired pneumonia
- chronic kidney disease
- acute kidney injury
- anemia
- type 2 diabetes

Disposition: home with follow-up.