Extended criteria (experimental). This is the broader ten-condition engine, kept as a secondary area. It shows ICD-10-CM codes and illustrative grouping effects for CDI staff. The primary surface is Before you sign (kidney, measurement only). All extended pages.

ENC-00083: Jalen Penhallow

49F · MRN55951630 · General Surgery · admitted Sat Nov 07, 2026 10:07 PM · discharged Tue Nov 10, 2026 01:22 PM · attending Dr. Wes Merriweather · 156 cm, 41.7 kg

Documented diagnoses (current)

Principal: “upper GI bleed” · K92.2 Gastrointestinal hemorrhage, unspecified
“moderate protein-calorie malnutrition” · E44.0 Moderate protein-calorie malnutrition
“hyponatremia” · E87.1 Hypo-osmolality and hyponatremia
“GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis

Illustrative grouping now: MS-DRG 378 GI hemorrhage with CC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 377.

Queries and events

No queries yet.

All rules applied

Rule Criteria Finding Outcome

Acute kidney injury

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule aki v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: meets_definition	`creat_ratio >= t.ratio_s1 or creat_rise_48h >= t.rise_abs or coalesce(uo_hours_lt_0_5 >= t.uo_s1_h, false)`	creat_ratio=1.035, 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	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=1.035, t.ratio_s3=3.0, creat_peak=0.89, 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=1.035, 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=0.02, 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 met

Specificity gap

Criteria support Acute blood loss anemia (D62); no corresponding diagnosis is documented.

Trace

Rule trace (rule blood_loss_anemia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: anaemic	`case(sex == 'M', hgb_nadir < t.hb_m, sex == 'F', hgb_nadir < t.hb_f, null)`	sex=F, hgb_nadir=9.76, 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=3.1, 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

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)
Step	Expression	Inputs and thresholds read	Result
derived: chronic	`egfr_n >= 2 and egfr_span_days >= t.chronic_days`	egfr_n=2, egfr_span_days=213, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=86.4, egfr_late=82.8	86.4
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=86.4, t.g2=60, egfr_late=82.8	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=86.4, 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=86.4, egfr_late=82.8, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=86.4, t.g2=60	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)
Step	Expression	Inputs and thresholds read	Result
derived: np_elevated	`coalesce(bnp_max >= t.bnp, false) or coalesce(ntprobnp_max >= t.ntprobnp, false)`	bnp_max=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 met

No gap

Supported as documented (E87.1).

Trace

Rule trace (rule hyponatremia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: severity	`case(na_min < t.profound, 'profound', na_min < t.moderate, 'moderate', na_min < t.low, 'mild', 'none')`	na_min=128.0, t.profound=125, t.moderate=130, t.low=135	moderate
outcome: met	`na_min < t.low and na_low_count >= t.repeat and na_treated`	na_min=128.0, t.low=135, na_low_count=4, t.repeat=2, na_treated=True	true

Malnutrition

Criteria met

No gap

Supported as documented (E44.0).

Trace

Rule trace (rule malnutrition v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: a_sev_intake	`intake_pct <= t.a_sev_intake_pct and intake_days >= t.a_sev_intake_days`	intake_pct=80.0, t.a_sev_intake_pct=50, intake_days=48.0, 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=80.0, t.a_mod_intake_pct=75, intake_days=48.0, 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=30.0, wt_loss_pct=5.0	false
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=30.0, wt_loss_pct=5.0	true
derived: c_sev_intake	`intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=80.0, t.c_intake_pct=75, intake_days=48.0, 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=80.0, t.c_intake_pct=75, intake_days=48.0, 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=30.0, wt_loss_pct=5.0	false
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=30.0, wt_loss_pct=5.0	true
derived: n_assessed	`known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced)`	intake_pct=80.0, wt_loss_pct=5.0, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown	5
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=False, a_sev_wt=False, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_sev_wt=False	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=False, a_mod_intake=False, a_sev_wt=False, a_mod_wt=True, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_mod_intake=False, c_sev_wt=False, c_mod_wt=True	3
outcome: severe	`n_severe >= 2`	n_severe=0	false
outcome: moderate	`n_moderate >= 2`	n_moderate=3	true

Obesity

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule obesity v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
outcome: not_adult	`age < t.adult`	age=49, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=17.1, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=17.1, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=17.1, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=17.1, t.c1=30	true

Pressure injury

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

Trace

Rule trace (rule pressure_injury v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: sacral	`wound_site == 'sacral'`	wound_site=unknown	unknown
outcome: no_wound_note	`not present(wound_stage)`	wound_stage=unknown	true

Acute respiratory failure

Criteria met

Specificity gap

Criteria support Acute respiratory failure with hypoxia (J96.01); no corresponding diagnosis is documented.

Trace

Rule trace (rule respiratory_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: measured	`present(spo2_min_ra) or present(pao2_min_ra) or present(pf_min)`	spo2_min_ra=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=28.0, 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)
Step	Expression	Inputs and thresholds read	Result
derived: sirs_temp	`coalesce(temp_max_48h > t.t_hi, false) or coalesce(temp_min_48h < t.t_lo, false)`	temp_max_48h=37.6, t.t_hi=38, temp_min_48h=36.6, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=83.0, t.hr=90	false
derived: sirs_rr	`coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false)`	rr_max_48h=28.0, 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=9.36, t.wbc_hi=12, wbc_min_48h=8.19, 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=219.0	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=0.51	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=0.89	0
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=0.86	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=0, sofa_renal_baseline=0	2
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=False, sofa_delta=2, 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 (25)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-002815	Sat Dec 13, 2025 09:15 AM	creatinine	0.83 mg/dL
LAB-002816	Wed Jul 15, 2026 10:05 AM	creatinine	0.86 mg/dL
LAB-002821	Sat Nov 07, 2026 10:32 PM	pao2	57.0 mmHg
LAB-002822	Sat Nov 07, 2026 10:32 PM	fio2	21.0 %
LAB-002817	Sat Nov 07, 2026 11:07 PM	creatinine	0.89 mg/dL
LAB-002823	Sat Nov 07, 2026 11:07 PM	sodium	130.0 mmol/L
LAB-002827	Sat Nov 07, 2026 11:07 PM	hemoglobin	12.9 g/dL
LAB-002831	Sat Nov 07, 2026 11:07 PM	wbc	8.19 x10^3/uL
LAB-002832	Sat Nov 07, 2026 11:07 PM	platelets	251.0 x10^3/uL
LAB-002839	Sat Nov 07, 2026 11:07 PM	bilirubin	0.51 mg/dL
LAB-002818	Sun Nov 08, 2026 05:00 AM	creatinine	0.86 mg/dL
LAB-002824	Sun Nov 08, 2026 05:00 AM	sodium	128.0 mmol/L
LAB-002828	Sun Nov 08, 2026 05:00 AM	hemoglobin	11.02 g/dL
LAB-002833	Sun Nov 08, 2026 05:00 AM	wbc	8.73 x10^3/uL
LAB-002834	Sun Nov 08, 2026 05:00 AM	platelets	219.0 x10^3/uL
LAB-002819	Mon Nov 09, 2026 05:00 AM	creatinine	0.87 mg/dL
LAB-002825	Mon Nov 09, 2026 05:00 AM	sodium	129.0 mmol/L
LAB-002829	Mon Nov 09, 2026 05:00 AM	hemoglobin	9.76 g/dL
LAB-002835	Mon Nov 09, 2026 05:00 AM	wbc	9.36 x10^3/uL
LAB-002836	Mon Nov 09, 2026 05:00 AM	platelets	252.0 x10^3/uL
LAB-002820	Tue Nov 10, 2026 05:00 AM	creatinine	0.88 mg/dL
LAB-002826	Tue Nov 10, 2026 05:00 AM	sodium	132.0 mmol/L
LAB-002830	Tue Nov 10, 2026 05:00 AM	hemoglobin	10.56 g/dL
LAB-002837	Tue Nov 10, 2026 05:00 AM	wbc	6.61 x10^3/uL
LAB-002838	Tue Nov 10, 2026 05:00 AM	platelets	270.0 x10^3/uL

Vitals (56)

Vitals
Row	When	Kind	Value	Detail
VIT-008153	Sat Nov 07, 2026 10:27 PM	spo2	86.0	room air
VIT-008154	Sat Nov 07, 2026 10:27 PM	rr	28.0
VIT-008177	Sat Nov 07, 2026 10:27 PM	temp_c	37.1
VIT-008178	Sat Nov 07, 2026 10:27 PM	hr	70.0
VIT-008179	Sat Nov 07, 2026 10:27 PM	map	90.0
VIT-008180	Sat Nov 07, 2026 10:27 PM	gcs	15.0
VIT-008155	Sat Nov 07, 2026 10:37 PM	o2_lpm	5.0	nasal cannula
VIT-008156	Sun Nov 08, 2026 06:27 AM	spo2	95.0	nasal cannula
VIT-008157	Sun Nov 08, 2026 06:27 AM	rr	20.0
VIT-008158	Sun Nov 08, 2026 06:27 AM	o2_lpm	2.0	nasal cannula
VIT-008181	Sun Nov 08, 2026 06:27 AM	temp_c	36.8
VIT-008182	Sun Nov 08, 2026 06:27 AM	hr	71.0
VIT-008183	Sun Nov 08, 2026 06:27 AM	map	78.0
VIT-008184	Sun Nov 08, 2026 06:27 AM	gcs	15.0
VIT-008159	Sun Nov 08, 2026 02:27 PM	spo2	91.0	nasal cannula
VIT-008160	Sun Nov 08, 2026 02:27 PM	rr	23.0
VIT-008161	Sun Nov 08, 2026 02:27 PM	o2_lpm	4.0	nasal cannula
VIT-008185	Sun Nov 08, 2026 02:27 PM	temp_c	37.2
VIT-008186	Sun Nov 08, 2026 02:27 PM	hr	69.0
VIT-008187	Sun Nov 08, 2026 02:27 PM	map	91.0
VIT-008188	Sun Nov 08, 2026 02:27 PM	gcs	15.0
VIT-008162	Sun Nov 08, 2026 10:27 PM	spo2	92.0	nasal cannula
VIT-008163	Sun Nov 08, 2026 10:27 PM	rr	20.0
VIT-008164	Sun Nov 08, 2026 10:27 PM	o2_lpm	4.0	nasal cannula
VIT-008189	Sun Nov 08, 2026 10:27 PM	temp_c	36.6
VIT-008190	Sun Nov 08, 2026 10:27 PM	hr	72.0
VIT-008191	Sun Nov 08, 2026 10:27 PM	map	75.0
VIT-008192	Sun Nov 08, 2026 10:27 PM	gcs	15.0
VIT-008165	Mon Nov 09, 2026 06:27 AM	spo2	91.0	nasal cannula
VIT-008166	Mon Nov 09, 2026 06:27 AM	rr	22.0
VIT-008167	Mon Nov 09, 2026 06:27 AM	o2_lpm	3.0	nasal cannula
VIT-008193	Mon Nov 09, 2026 06:27 AM	temp_c	36.7
VIT-008194	Mon Nov 09, 2026 06:27 AM	hr	79.0
VIT-008195	Mon Nov 09, 2026 06:27 AM	map	86.0
VIT-008196	Mon Nov 09, 2026 06:27 AM	gcs	15.0
VIT-008168	Mon Nov 09, 2026 02:27 PM	spo2	92.0	nasal cannula
VIT-008169	Mon Nov 09, 2026 02:27 PM	rr	26.0
VIT-008170	Mon Nov 09, 2026 02:27 PM	o2_lpm	4.0	nasal cannula
VIT-008197	Mon Nov 09, 2026 02:27 PM	temp_c	37.6
VIT-008198	Mon Nov 09, 2026 02:27 PM	hr	83.0
VIT-008199	Mon Nov 09, 2026 02:27 PM	map	89.0
VIT-008200	Mon Nov 09, 2026 02:27 PM	gcs	15.0
VIT-008171	Mon Nov 09, 2026 10:27 PM	spo2	92.0	nasal cannula
VIT-008172	Mon Nov 09, 2026 10:27 PM	rr	21.0
VIT-008173	Mon Nov 09, 2026 10:27 PM	o2_lpm	3.0	nasal cannula
VIT-008201	Mon Nov 09, 2026 10:27 PM	temp_c	37.5
VIT-008202	Mon Nov 09, 2026 10:27 PM	hr	76.0
VIT-008203	Mon Nov 09, 2026 10:27 PM	map	79.0
VIT-008204	Mon Nov 09, 2026 10:27 PM	gcs	15.0
VIT-008174	Tue Nov 10, 2026 06:27 AM	spo2	91.0	nasal cannula
VIT-008175	Tue Nov 10, 2026 06:27 AM	rr	25.0
VIT-008176	Tue Nov 10, 2026 06:27 AM	o2_lpm	4.0	nasal cannula
VIT-008205	Tue Nov 10, 2026 06:27 AM	temp_c	37.3
VIT-008206	Tue Nov 10, 2026 06:27 AM	hr	80.0
VIT-008207	Tue Nov 10, 2026 06:27 AM	map	78.0
VIT-008208	Tue Nov 10, 2026 06:27 AM	gcs	15.0

Medications, orders, echo, history (2)

ORD-000073 11-08 01:07 fluid_restriction: fluid restriction 1.2 L/day
ORD-000074 11-08 09:00 transfusion_prbc: transfuse PRBC

Notes

History and physical · DOC-000283 · Dr. Wes Merriweather (attending) · Sun Nov 08, 2026 01:07 AM

Cited facts from this note (1)

bleeding_source: coffee-ground emesis · cited p. 1, line 5 · confidence 0.85

Show source for bleeding_source

… ice: General Surgery Attending: Dr. Wes Merriweather History of present illness: 49-year-old woman admitted with upper GI bleed. Presented after two days of coffee-ground emesis; GI consulted for endoscopy. Past medical history: GERD. Review of systems otherwise negative. Exam: Lungs: labored respirations. Assessment and plan: 1. Upper …

Source document DOC-000283: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Jalen Penhallow   MRN: MRN55951630   Admitted: 2026-11-07 22:07
Service: General Surgery   Attending: Dr. Wes Merriweather

History of present illness: 49-year-old woman admitted with upper GI bleed. Presented after two days of coffee-ground emesis; GI consulted for endoscopy.
Past medical history: GERD.
Review of systems otherwise negative.
Exam: Lungs: labored respirations.
Assessment and plan:
1. Upper GI bleed: PPI, GI following.

Nutrition assessment · DOC-000282 · Viggo Ravensworth, RD (dietitian) · Mon Nov 09, 2026 03:07 AM

Cited facts from this note (8)

fat_loss: mild · cited p. 1, line 7 · confidence 0.90

Show source for fat_loss

… text: chronic illness Intake: estimated energy intake 80% of needs for 48 days. Weight history: 5.0% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
fluid_accumulation: none · cited p. 1, line 7 · confidence 0.90

Show source for fluid_accumulation

… e 80% of needs for 48 days. Weight history: 5.0% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
intake_days: 48 · cited p. 1, line 5 · confidence 0.95

Show source for intake_days

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Jalen Penhallow MRN: MRN55951630 Context: chronic illness Intake: estimated energy intake 80% of needs for 48 days. Weight history: 5.0% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Rec …
intake_pct: 80 · cited p. 1, line 5 · confidence 0.95

Show source for intake_pct

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Jalen Penhallow MRN: MRN55951630 Context: chronic illness Intake: estimated energy intake 80% of needs for 48 days. Weight history: 5.0% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Rec …
muscle_loss: mild · cited p. 1, line 7 · confidence 0.90

Show source for muscle_loss

… stimated energy intake 80% of needs for 48 days. Weight history: 5.0% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
nutrition_context: chronic · cited p. 1, line 4 · confidence 0.95

Show source for nutrition_context

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Jalen Penhallow MRN: MRN55951630 Context: chronic illness Intake: estimated energy intake 80% of needs for 48 days. Weight history: 5.0% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutan …
weight_loss_days: 30 · cited p. 1, line 6 · confidence 0.95

Show source for weight_loss_days

… ered Dietitian) Patient: Jalen Penhallow MRN: MRN55951630 Context: chronic illness Intake: estimated energy intake 80% of needs for 48 days. Weight history: 5.0% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; cal …
weight_loss_pct: 5 · cited p. 1, line 6 · confidence 0.95

Show source for weight_loss_pct

… ered Dietitian) Patient: Jalen Penhallow MRN: MRN55951630 Context: chronic illness Intake: estimated energy intake 80% of needs for 48 days. Weight history: 5.0% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; cal …

Source document DOC-000282: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Jalen Penhallow   MRN: MRN55951630

Context: chronic illness
Intake: estimated energy intake 80% of needs for 48 days.
Weight history: 5.0% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Recommendations: high-protein oral supplement; calorie counts; weekly weights.

Progress note · DOC-000284 · Dr. Wes Merriweather (attending) · Tue Nov 10, 2026 01:07 AM

Source document DOC-000284: Progress note (synthetic)

PROGRESS NOTE (Attending)
Patient: Jalen Penhallow   MRN: MRN55951630   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. Moderate protein-calorie malnutrition: dietitian following, supplements.
3. Hyponatremia: trend sodium.

Attending: Dr. Wes Merriweather

Discharge summary · DOC-000285 · Dr. Wes Merriweather (attending) · Tue Nov 10, 2026 01:22 PM

Source document DOC-000285: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Jalen Penhallow   MRN: MRN55951630
Admitted 2026-11-07; discharged 2026-11-10.

Discharge diagnoses:
- upper GI bleed
- moderate protein-calorie malnutrition
- hyponatremia
- GERD

Disposition: home with follow-up.