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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-00076: Florian Ashgrove

79M · MRN46024799 · Pulmonology · admitted Sun Nov 08, 2026 02:21 PM · in hospital · attending Dr. Gideon Zeller · resident Dr. Greta Kowalczyk · 182 cm, 128.4 kg

Documented diagnoses (current)

  • Principal: “COPD exacerbation” · J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
  • “class 2 obesity” · E66.812 Obesity, class 2
  • “CKD stage 3a” · N18.31 Chronic kidney disease, stage 3a
  • “acute hypoxic respiratory failure” · J96.01 Acute respiratory failure with hypoxia

Illustrative grouping now: MS-DRG 190 Chronic obstructive pulmonary disease with MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 190.

Queries and events

No queries yet.

All rules applied

Every rule's outcome for this encounter (clean results included)
RuleCriteriaFindingOutcome
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)
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=1.061, t.ratio_s1=1.5, creat_rise_48h=0.09, 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=1.061, 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=1.061, 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=0.09, 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)
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=14.73, 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=0.2, 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=0.2, t.drop_min=1.0, prbc_units=0 false
outcome: not_anaemic present(hgb_nadir) and not anaemic hgb_nadir=14.73, anaemic=False true
Chronic kidney disease Criteria met No gap Supported as documented (N18.31).
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=259, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=49.8, egfr_late=54.9 54.9
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=49.8, t.g2=60, egfr_late=54.9 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=54.9, 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=49.8, egfr_late=54.9, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=54.9, t.g2=60 false
outcome: g3a category == 'G3a' category=G3a 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 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 No gap Supported as documented (E66.812).
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=79, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=38.8, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=38.8, t.c2=35 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=84.0, 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=84.0, t.spo2_ra=88, pao2_min_ra=unknown, t.pao2=60, pf_min=unknown, t.pf=300 true
derived: distress coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support rr_max=30.0, t.rr_distress=28, wob_increased=True, 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=37.4, 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=88.0, 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=30.0, 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=9.72, t.wbc_hi=12, wbc_min_48h=6.15, 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=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=203.0 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=0.86 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=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=1.32 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=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 (33)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-002583Fri Jan 02, 2026 09:15 AMcreatinine1.43 mg/dL
LAB-002584Sat Sep 19, 2026 10:05 AMcreatinine1.32 mg/dL
LAB-002585Sun Nov 08, 2026 03:21 PMcreatinine1.31 mg/dL
LAB-002591Sun Nov 08, 2026 03:21 PMsodium137.0 mmol/L
LAB-002597Sun Nov 08, 2026 03:21 PMhemoglobin14.98 g/dL
LAB-002603Sun Nov 08, 2026 03:21 PMwbc6.15 x10^3/uL
LAB-002604Sun Nov 08, 2026 03:21 PMplatelets205.0 x10^3/uL
LAB-002615Sun Nov 08, 2026 03:21 PMbilirubin0.86 mg/dL
LAB-002586Mon Nov 09, 2026 05:00 AMcreatinine1.4 mg/dL
LAB-002592Mon Nov 09, 2026 05:00 AMsodium142.0 mmol/L
LAB-002598Mon Nov 09, 2026 05:00 AMhemoglobin14.81 g/dL
LAB-002605Mon Nov 09, 2026 05:00 AMwbc6.75 x10^3/uL
LAB-002606Mon Nov 09, 2026 05:00 AMplatelets243.0 x10^3/uL
LAB-002587Tue Nov 10, 2026 05:00 AMcreatinine1.39 mg/dL
LAB-002593Tue Nov 10, 2026 05:00 AMsodium138.0 mmol/L
LAB-002599Tue Nov 10, 2026 05:00 AMhemoglobin14.74 g/dL
LAB-002607Tue Nov 10, 2026 05:00 AMwbc9.72 x10^3/uL
LAB-002608Tue Nov 10, 2026 05:00 AMplatelets203.0 x10^3/uL
LAB-002588Wed Nov 11, 2026 05:00 AMcreatinine1.34 mg/dL
LAB-002594Wed Nov 11, 2026 05:00 AMsodium136.0 mmol/L
LAB-002600Wed Nov 11, 2026 05:00 AMhemoglobin14.81 g/dL
LAB-002609Wed Nov 11, 2026 05:00 AMwbc6.24 x10^3/uL
LAB-002610Wed Nov 11, 2026 05:00 AMplatelets254.0 x10^3/uL
LAB-002589Thu Nov 12, 2026 05:00 AMcreatinine1.39 mg/dL
LAB-002595Thu Nov 12, 2026 05:00 AMsodium142.0 mmol/L
LAB-002601Thu Nov 12, 2026 05:00 AMhemoglobin14.73 g/dL
LAB-002611Thu Nov 12, 2026 05:00 AMwbc9.63 x10^3/uL
LAB-002612Thu Nov 12, 2026 05:00 AMplatelets225.0 x10^3/uL
LAB-002590Fri Nov 13, 2026 05:00 AMcreatinine1.32 mg/dL
LAB-002596Fri Nov 13, 2026 05:00 AMsodium137.0 mmol/L
LAB-002602Fri Nov 13, 2026 05:00 AMhemoglobin15.01 g/dL
LAB-002613Fri Nov 13, 2026 05:00 AMwbc10.24 x10^3/uL
LAB-002614Fri Nov 13, 2026 05:00 AMplatelets250.0 x10^3/uL
Vitals (112)
Vitals
RowWhenKindValueDetail
VIT-007454Sun Nov 08, 2026 02:41 PMspo284.0room air
VIT-007455Sun Nov 08, 2026 02:41 PMrr30.0
VIT-007502Sun Nov 08, 2026 02:41 PMtemp_c37.4
VIT-007503Sun Nov 08, 2026 02:41 PMhr70.0
VIT-007504Sun Nov 08, 2026 02:41 PMmap81.0
VIT-007505Sun Nov 08, 2026 02:41 PMgcs15.0
VIT-007456Sun Nov 08, 2026 02:51 PMo2_lpm5.0nasal cannula
VIT-007457Sun Nov 08, 2026 10:41 PMspo295.0nasal cannula
VIT-007458Sun Nov 08, 2026 10:41 PMrr24.0
VIT-007459Sun Nov 08, 2026 10:41 PMo2_lpm3.0nasal cannula
VIT-007506Sun Nov 08, 2026 10:41 PMtemp_c36.6
VIT-007507Sun Nov 08, 2026 10:41 PMhr72.0
VIT-007508Sun Nov 08, 2026 10:41 PMmap88.0
VIT-007509Sun Nov 08, 2026 10:41 PMgcs15.0
VIT-007460Mon Nov 09, 2026 06:41 AMspo292.0nasal cannula
VIT-007461Mon Nov 09, 2026 06:41 AMrr25.0
VIT-007462Mon Nov 09, 2026 06:41 AMo2_lpm3.0nasal cannula
VIT-007510Mon Nov 09, 2026 06:41 AMtemp_c37.3
VIT-007511Mon Nov 09, 2026 06:41 AMhr88.0
VIT-007512Mon Nov 09, 2026 06:41 AMmap78.0
VIT-007513Mon Nov 09, 2026 06:41 AMgcs15.0
VIT-007463Mon Nov 09, 2026 02:41 PMspo293.0nasal cannula
VIT-007464Mon Nov 09, 2026 02:41 PMrr21.0
VIT-007465Mon Nov 09, 2026 02:41 PMo2_lpm2.0nasal cannula
VIT-007514Mon Nov 09, 2026 02:41 PMtemp_c37.2
VIT-007515Mon Nov 09, 2026 02:41 PMhr68.0
VIT-007516Mon Nov 09, 2026 02:41 PMmap76.0
VIT-007517Mon Nov 09, 2026 02:41 PMgcs15.0
VIT-007466Mon Nov 09, 2026 10:41 PMspo294.0nasal cannula
VIT-007467Mon Nov 09, 2026 10:41 PMrr23.0
VIT-007468Mon Nov 09, 2026 10:41 PMo2_lpm2.0nasal cannula
VIT-007518Mon Nov 09, 2026 10:41 PMtemp_c36.9
VIT-007519Mon Nov 09, 2026 10:41 PMhr81.0
VIT-007520Mon Nov 09, 2026 10:41 PMmap86.0
VIT-007521Mon Nov 09, 2026 10:41 PMgcs15.0
VIT-007469Tue Nov 10, 2026 06:41 AMspo292.0nasal cannula
VIT-007470Tue Nov 10, 2026 06:41 AMrr22.0
VIT-007471Tue Nov 10, 2026 06:41 AMo2_lpm2.0nasal cannula
VIT-007522Tue Nov 10, 2026 06:41 AMtemp_c37.4
VIT-007523Tue Nov 10, 2026 06:41 AMhr82.0
VIT-007524Tue Nov 10, 2026 06:41 AMmap92.0
VIT-007525Tue Nov 10, 2026 06:41 AMgcs15.0
VIT-007472Tue Nov 10, 2026 02:41 PMspo295.0nasal cannula
VIT-007473Tue Nov 10, 2026 02:41 PMrr26.0
VIT-007474Tue Nov 10, 2026 02:41 PMo2_lpm2.0nasal cannula
VIT-007526Tue Nov 10, 2026 02:41 PMtemp_c37.4
VIT-007527Tue Nov 10, 2026 02:41 PMhr72.0
VIT-007528Tue Nov 10, 2026 02:41 PMmap82.0
VIT-007529Tue Nov 10, 2026 02:41 PMgcs15.0
VIT-007475Tue Nov 10, 2026 10:41 PMspo293.0nasal cannula
VIT-007476Tue Nov 10, 2026 10:41 PMrr24.0
VIT-007477Tue Nov 10, 2026 10:41 PMo2_lpm4.0nasal cannula
VIT-007530Tue Nov 10, 2026 10:41 PMtemp_c37.1
VIT-007531Tue Nov 10, 2026 10:41 PMhr84.0
VIT-007532Tue Nov 10, 2026 10:41 PMmap83.0
VIT-007533Tue Nov 10, 2026 10:41 PMgcs15.0
VIT-007478Wed Nov 11, 2026 06:41 AMspo294.0nasal cannula
VIT-007479Wed Nov 11, 2026 06:41 AMrr24.0
VIT-007480Wed Nov 11, 2026 06:41 AMo2_lpm2.0nasal cannula
VIT-007534Wed Nov 11, 2026 06:41 AMtemp_c37.5
VIT-007535Wed Nov 11, 2026 06:41 AMhr75.0
VIT-007536Wed Nov 11, 2026 06:41 AMmap74.0
VIT-007537Wed Nov 11, 2026 06:41 AMgcs15.0
VIT-007481Wed Nov 11, 2026 02:41 PMspo295.0nasal cannula
VIT-007482Wed Nov 11, 2026 02:41 PMrr24.0
VIT-007483Wed Nov 11, 2026 02:41 PMo2_lpm2.0nasal cannula
VIT-007538Wed Nov 11, 2026 02:41 PMtemp_c36.8
VIT-007539Wed Nov 11, 2026 02:41 PMhr83.0
VIT-007540Wed Nov 11, 2026 02:41 PMmap81.0
VIT-007541Wed Nov 11, 2026 02:41 PMgcs15.0
VIT-007484Wed Nov 11, 2026 10:41 PMspo292.0nasal cannula
VIT-007485Wed Nov 11, 2026 10:41 PMrr23.0
VIT-007486Wed Nov 11, 2026 10:41 PMo2_lpm4.0nasal cannula
VIT-007542Wed Nov 11, 2026 10:41 PMtemp_c37.1
VIT-007543Wed Nov 11, 2026 10:41 PMhr73.0
VIT-007544Wed Nov 11, 2026 10:41 PMmap81.0
VIT-007545Wed Nov 11, 2026 10:41 PMgcs15.0
VIT-007487Thu Nov 12, 2026 06:41 AMspo295.0nasal cannula
VIT-007488Thu Nov 12, 2026 06:41 AMrr23.0
VIT-007489Thu Nov 12, 2026 06:41 AMo2_lpm2.0nasal cannula
VIT-007546Thu Nov 12, 2026 06:41 AMtemp_c36.9
VIT-007547Thu Nov 12, 2026 06:41 AMhr90.0
VIT-007548Thu Nov 12, 2026 06:41 AMmap75.0
VIT-007549Thu Nov 12, 2026 06:41 AMgcs15.0
VIT-007490Thu Nov 12, 2026 02:41 PMspo294.0nasal cannula
VIT-007491Thu Nov 12, 2026 02:41 PMrr24.0
VIT-007492Thu Nov 12, 2026 02:41 PMo2_lpm3.0nasal cannula
VIT-007550Thu Nov 12, 2026 02:41 PMtemp_c36.6
VIT-007551Thu Nov 12, 2026 02:41 PMhr69.0
VIT-007552Thu Nov 12, 2026 02:41 PMmap83.0
VIT-007553Thu Nov 12, 2026 02:41 PMgcs15.0
VIT-007493Thu Nov 12, 2026 10:41 PMspo293.0nasal cannula
VIT-007494Thu Nov 12, 2026 10:41 PMrr21.0
VIT-007495Thu Nov 12, 2026 10:41 PMo2_lpm4.0nasal cannula
VIT-007554Thu Nov 12, 2026 10:41 PMtemp_c36.8
VIT-007555Thu Nov 12, 2026 10:41 PMhr70.0
VIT-007556Thu Nov 12, 2026 10:41 PMmap86.0
VIT-007557Thu Nov 12, 2026 10:41 PMgcs15.0
VIT-007496Fri Nov 13, 2026 06:41 AMspo291.0nasal cannula
VIT-007497Fri Nov 13, 2026 06:41 AMrr20.0
VIT-007498Fri Nov 13, 2026 06:41 AMo2_lpm3.0nasal cannula
VIT-007558Fri Nov 13, 2026 06:41 AMtemp_c37.1
VIT-007559Fri Nov 13, 2026 06:41 AMhr71.0
VIT-007560Fri Nov 13, 2026 06:41 AMmap75.0
VIT-007561Fri Nov 13, 2026 06:41 AMgcs15.0
VIT-007499Fri Nov 13, 2026 02:41 PMspo291.0nasal cannula
VIT-007500Fri Nov 13, 2026 02:41 PMrr23.0
VIT-007501Fri Nov 13, 2026 02:41 PMo2_lpm3.0nasal cannula
VIT-007562Fri Nov 13, 2026 02:41 PMtemp_c37.1
VIT-007563Fri Nov 13, 2026 02:41 PMhr72.0
VIT-007564Fri Nov 13, 2026 02:41 PMmap90.0
VIT-007565Fri Nov 13, 2026 02:41 PMgcs15.0
Medications, orders, echo, history (0)

Notes

History and physical · DOC-000263 · Dr. Greta Kowalczyk (resident) · Sun Nov 08, 2026 05:21 PM

Cited facts from this note (1)
work_of_breathing
increased · cited p. 1, line 8 · confidence 0.90
Show source for work_of_breathing
… f present illness: 79-year-old man admitted with COPD exacerbation. Past medical history: none significant. Review of systems otherwise negative. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. COPD exacerbation: bronchodilators and steroids. 2. CKD stage 3a: renally dose medications.
Source document DOC-000263: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Florian Ashgrove   MRN: MRN46024799   Admitted: 2026-11-08 14:21
Service: Pulmonology   Attending: Dr. Gideon Zeller

History of present illness: 79-year-old man admitted with COPD exacerbation. 
Past medical history: none significant.
Review of systems otherwise negative.
Exam: Lungs: increased work of breathing with accessory muscle use.
Assessment and plan:
1. COPD exacerbation: bronchodilators and steroids.
2. CKD stage 3a: renally dose medications.

Nutrition assessment · DOC-000262 · Vera Pemberton, RD (dietitian) · Mon Nov 09, 2026 07:21 PM

Cited facts from this note (5)
fat_loss
none · cited p. 1, line 7 · confidence 0.90
Show source for fat_loss
… MRN: MRN46024799 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: Florian Ashgrove MRN: MRN46024799 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: Florian Ashgrove MRN: MRN46024799 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-000262: Nutrition assessment (synthetic)
NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Florian Ashgrove   MRN: MRN46024799

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-000264 · Dr. Greta Kowalczyk (resident) · Fri Nov 13, 2026 11:55 AM · awaiting cosign

Source document DOC-000264: Progress note (synthetic)
PROGRESS NOTE (Resident)
Patient: Florian Ashgrove   MRN: MRN46024799   Hospital day 5

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. COPD exacerbation: continue current management.
2. Class 2 obesity: counsel on weight.
3. Acute hypoxic respiratory failure: supplemental oxygen, wean as tolerated.

Resident: Dr. Greta Kowalczyk   Attending cosign: pending