Skip to main content
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.

← All encounters

ENC-00114: Yusuf Whitlock

54M · MRN46676005 · Hospital Medicine · admitted Wed Oct 28, 2026 05:13 PM · discharged Thu Nov 05, 2026 02:12 PM · attending Dr. Odette Galloway · 177 cm, 114.9 kg

Documented diagnoses (current)

  • Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
  • “AKI” · N17.9 Acute kidney failure, unspecified
  • “acute blood loss anemia” · D62 Acute posthemorrhagic anemia
  • “hyperlipidemia” · E78.5 Hyperlipidemia, 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 195.

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 Clinical validation gap Documented “AKI” (N17.9) but the criteria are not met: KDIGO creatinine and urine-output criteria not met.
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=1.045, t.ratio_s1=1.5, creat_rise_48h=0.06, 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=1.045, t.ratio_s3=3.0, creat_peak=1.15, 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=1.045, 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=0.06, 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 Clinical validation gap Documented “acute blood loss anemia” (D62) is more specific than the criteria support (Anemia (acute blood-loss criteria not met), D64.9).
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=11.31, 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=0.4, 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=True, acute_fall=False false
outcome: anaemia_only anaemic and hgb_drop < t.drop_min and prbc_units == 0 anaemic=True, hgb_drop=0.4, t.drop_min=1.0, prbc_units=0 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=319, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=81.5, egfr_late=79.8 81.5
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=81.5, t.g2=60, egfr_late=79.8 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=81.5, 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=81.5, egfr_late=79.8, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=81.5, t.g2=60 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 2 (E66.812); 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=54, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=36.7, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=36.7, 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 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=85.0, 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=10.33, t.wbc_hi=12, wbc_min_48h=9.42, 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=197.0 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=0.61 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=78.0 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=1.15 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=1.1 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=0, sofa_renal_baseline=0 0
derived: sepsis3 infection_documented and sofa_delta >= t.sofa_delta infection_documented=True, sofa_delta=0, t.sofa_delta=2 false
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=False, 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=False, sepsis2=False false
outcome: sepsis3_only sepsis3 sepsis3=False false
outcome: definitions_disagree sepsis2 sepsis2=False false
outcome: neither true — true

Structured data

Labs (48)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-003874Sun Sep 14, 2025 09:15 AMcreatinine1.08 mg/dL
LAB-003875Thu Jul 30, 2026 10:05 AMcreatinine1.1 mg/dL
LAB-003876Wed Oct 28, 2026 06:13 PMcreatinine1.09 mg/dL
LAB-003885Wed Oct 28, 2026 06:13 PMsodium138.0 mmol/L
LAB-003894Wed Oct 28, 2026 06:13 PMhemoglobin11.71 g/dL
LAB-003903Wed Oct 28, 2026 06:13 PMwbc10.04 x10^3/uL
LAB-003904Wed Oct 28, 2026 06:13 PMplatelets282.0 x10^3/uL
LAB-003921Wed Oct 28, 2026 06:13 PMbilirubin0.61 mg/dL
LAB-003877Thu Oct 29, 2026 05:00 AMcreatinine1.15 mg/dL
LAB-003886Thu Oct 29, 2026 05:00 AMsodium140.0 mmol/L
LAB-003895Thu Oct 29, 2026 05:00 AMhemoglobin11.31 g/dL
LAB-003905Thu Oct 29, 2026 05:00 AMwbc10.33 x10^3/uL
LAB-003906Thu Oct 29, 2026 05:00 AMplatelets255.0 x10^3/uL
LAB-003878Fri Oct 30, 2026 05:00 AMcreatinine1.08 mg/dL
LAB-003887Fri Oct 30, 2026 05:00 AMsodium142.0 mmol/L
LAB-003896Fri Oct 30, 2026 05:00 AMhemoglobin11.71 g/dL
LAB-003907Fri Oct 30, 2026 05:00 AMwbc9.42 x10^3/uL
LAB-003908Fri Oct 30, 2026 05:00 AMplatelets197.0 x10^3/uL
LAB-003879Sat Oct 31, 2026 05:00 AMcreatinine1.1 mg/dL
LAB-003888Sat Oct 31, 2026 05:00 AMsodium137.0 mmol/L
LAB-003897Sat Oct 31, 2026 05:00 AMhemoglobin11.31 g/dL
LAB-003909Sat Oct 31, 2026 05:00 AMwbc9.08 x10^3/uL
LAB-003910Sat Oct 31, 2026 05:00 AMplatelets246.0 x10^3/uL
LAB-003880Sun Nov 01, 2026 05:00 AMcreatinine1.08 mg/dL
LAB-003889Sun Nov 01, 2026 05:00 AMsodium138.0 mmol/L
LAB-003898Sun Nov 01, 2026 05:00 AMhemoglobin11.71 g/dL
LAB-003911Sun Nov 01, 2026 05:00 AMwbc6.8 x10^3/uL
LAB-003912Sun Nov 01, 2026 05:00 AMplatelets230.0 x10^3/uL
LAB-003881Mon Nov 02, 2026 05:00 AMcreatinine1.14 mg/dL
LAB-003890Mon Nov 02, 2026 05:00 AMsodium136.0 mmol/L
LAB-003899Mon Nov 02, 2026 05:00 AMhemoglobin11.31 g/dL
LAB-003913Mon Nov 02, 2026 05:00 AMwbc10.56 x10^3/uL
LAB-003914Mon Nov 02, 2026 05:00 AMplatelets247.0 x10^3/uL
LAB-003882Tue Nov 03, 2026 05:00 AMcreatinine1.14 mg/dL
LAB-003891Tue Nov 03, 2026 05:00 AMsodium142.0 mmol/L
LAB-003900Tue Nov 03, 2026 05:00 AMhemoglobin11.71 g/dL
LAB-003915Tue Nov 03, 2026 05:00 AMwbc10.61 x10^3/uL
LAB-003916Tue Nov 03, 2026 05:00 AMplatelets177.0 x10^3/uL
LAB-003883Wed Nov 04, 2026 05:00 AMcreatinine1.1 mg/dL
LAB-003892Wed Nov 04, 2026 05:00 AMsodium138.0 mmol/L
LAB-003901Wed Nov 04, 2026 05:00 AMhemoglobin11.31 g/dL
LAB-003917Wed Nov 04, 2026 05:00 AMwbc10.76 x10^3/uL
LAB-003918Wed Nov 04, 2026 05:00 AMplatelets262.0 x10^3/uL
LAB-003884Thu Nov 05, 2026 05:00 AMcreatinine1.12 mg/dL
LAB-003893Thu Nov 05, 2026 05:00 AMsodium136.0 mmol/L
LAB-003902Thu Nov 05, 2026 05:00 AMhemoglobin11.71 g/dL
LAB-003919Thu Nov 05, 2026 05:00 AMwbc8.95 x10^3/uL
LAB-003920Thu Nov 05, 2026 05:00 AMplatelets223.0 x10^3/uL
Vitals (144)
Vitals
RowWhenKindValueDetail
VIT-011122Wed Oct 28, 2026 05:33 PMspo299.0room air
VIT-011123Wed Oct 28, 2026 05:33 PMrr17.0
VIT-011170Wed Oct 28, 2026 05:33 PMtemp_c37.1
VIT-011171Wed Oct 28, 2026 05:33 PMhr71.0
VIT-011172Wed Oct 28, 2026 05:33 PMmap85.0
VIT-011173Wed Oct 28, 2026 05:33 PMgcs15.0
VIT-011124Thu Oct 29, 2026 01:33 AMspo296.0room air
VIT-011125Thu Oct 29, 2026 01:33 AMrr18.0
VIT-011174Thu Oct 29, 2026 01:33 AMtemp_c37.0
VIT-011175Thu Oct 29, 2026 01:33 AMhr81.0
VIT-011176Thu Oct 29, 2026 01:33 AMmap92.0
VIT-011177Thu Oct 29, 2026 01:33 AMgcs15.0
VIT-011126Thu Oct 29, 2026 09:33 AMspo295.0room air
VIT-011127Thu Oct 29, 2026 09:33 AMrr20.0
VIT-011178Thu Oct 29, 2026 09:33 AMtemp_c36.6
VIT-011179Thu Oct 29, 2026 09:33 AMhr85.0
VIT-011180Thu Oct 29, 2026 09:33 AMmap91.0
VIT-011181Thu Oct 29, 2026 09:33 AMgcs15.0
VIT-011128Thu Oct 29, 2026 05:33 PMspo296.0room air
VIT-011129Thu Oct 29, 2026 05:33 PMrr18.0
VIT-011182Thu Oct 29, 2026 05:33 PMtemp_c37.5
VIT-011183Thu Oct 29, 2026 05:33 PMhr71.0
VIT-011184Thu Oct 29, 2026 05:33 PMmap78.0
VIT-011185Thu Oct 29, 2026 05:33 PMgcs15.0
VIT-011130Fri Oct 30, 2026 01:33 AMspo295.0room air
VIT-011131Fri Oct 30, 2026 01:33 AMrr16.0
VIT-011186Fri Oct 30, 2026 01:33 AMtemp_c36.6
VIT-011187Fri Oct 30, 2026 01:33 AMhr84.0
VIT-011188Fri Oct 30, 2026 01:33 AMmap90.0
VIT-011189Fri Oct 30, 2026 01:33 AMgcs15.0
VIT-011132Fri Oct 30, 2026 09:33 AMspo299.0room air
VIT-011133Fri Oct 30, 2026 09:33 AMrr14.0
VIT-011190Fri Oct 30, 2026 09:33 AMtemp_c37.2
VIT-011191Fri Oct 30, 2026 09:33 AMhr77.0
VIT-011192Fri Oct 30, 2026 09:33 AMmap88.0
VIT-011193Fri Oct 30, 2026 09:33 AMgcs15.0
VIT-011134Fri Oct 30, 2026 05:33 PMspo298.0room air
VIT-011135Fri Oct 30, 2026 05:33 PMrr18.0
VIT-011194Fri Oct 30, 2026 05:33 PMtemp_c37.3
VIT-011195Fri Oct 30, 2026 05:33 PMhr88.0
VIT-011196Fri Oct 30, 2026 05:33 PMmap82.0
VIT-011197Fri Oct 30, 2026 05:33 PMgcs15.0
VIT-011136Sat Oct 31, 2026 01:33 AMspo294.0room air
VIT-011137Sat Oct 31, 2026 01:33 AMrr14.0
VIT-011198Sat Oct 31, 2026 01:33 AMtemp_c37.1
VIT-011199Sat Oct 31, 2026 01:33 AMhr73.0
VIT-011200Sat Oct 31, 2026 01:33 AMmap86.0
VIT-011201Sat Oct 31, 2026 01:33 AMgcs15.0
VIT-011138Sat Oct 31, 2026 09:33 AMspo299.0room air
VIT-011139Sat Oct 31, 2026 09:33 AMrr17.0
VIT-011202Sat Oct 31, 2026 09:33 AMtemp_c37.5
VIT-011203Sat Oct 31, 2026 09:33 AMhr85.0
VIT-011204Sat Oct 31, 2026 09:33 AMmap81.0
VIT-011205Sat Oct 31, 2026 09:33 AMgcs15.0
VIT-011140Sat Oct 31, 2026 05:33 PMspo299.0room air
VIT-011141Sat Oct 31, 2026 05:33 PMrr19.0
VIT-011206Sat Oct 31, 2026 05:33 PMtemp_c37.2
VIT-011207Sat Oct 31, 2026 05:33 PMhr70.0
VIT-011208Sat Oct 31, 2026 05:33 PMmap74.0
VIT-011209Sat Oct 31, 2026 05:33 PMgcs15.0
VIT-011142Sun Nov 01, 2026 01:33 AMspo298.0room air
VIT-011143Sun Nov 01, 2026 01:33 AMrr20.0
VIT-011210Sun Nov 01, 2026 01:33 AMtemp_c36.5
VIT-011211Sun Nov 01, 2026 01:33 AMhr88.0
VIT-011212Sun Nov 01, 2026 01:33 AMmap74.0
VIT-011213Sun Nov 01, 2026 01:33 AMgcs15.0
VIT-011144Sun Nov 01, 2026 09:33 AMspo294.0room air
VIT-011145Sun Nov 01, 2026 09:33 AMrr17.0
VIT-011214Sun Nov 01, 2026 09:33 AMtemp_c36.7
VIT-011215Sun Nov 01, 2026 09:33 AMhr85.0
VIT-011216Sun Nov 01, 2026 09:33 AMmap78.0
VIT-011217Sun Nov 01, 2026 09:33 AMgcs15.0
VIT-011146Sun Nov 01, 2026 05:33 PMspo296.0room air
VIT-011147Sun Nov 01, 2026 05:33 PMrr17.0
VIT-011218Sun Nov 01, 2026 05:33 PMtemp_c37.4
VIT-011219Sun Nov 01, 2026 05:33 PMhr90.0
VIT-011220Sun Nov 01, 2026 05:33 PMmap83.0
VIT-011221Sun Nov 01, 2026 05:33 PMgcs15.0
VIT-011148Mon Nov 02, 2026 01:33 AMspo296.0room air
VIT-011149Mon Nov 02, 2026 01:33 AMrr16.0
VIT-011222Mon Nov 02, 2026 01:33 AMtemp_c37.4
VIT-011223Mon Nov 02, 2026 01:33 AMhr79.0
VIT-011224Mon Nov 02, 2026 01:33 AMmap80.0
VIT-011225Mon Nov 02, 2026 01:33 AMgcs15.0
VIT-011150Mon Nov 02, 2026 09:33 AMspo294.0room air
VIT-011151Mon Nov 02, 2026 09:33 AMrr16.0
VIT-011226Mon Nov 02, 2026 09:33 AMtemp_c36.9
VIT-011227Mon Nov 02, 2026 09:33 AMhr84.0
VIT-011228Mon Nov 02, 2026 09:33 AMmap87.0
VIT-011229Mon Nov 02, 2026 09:33 AMgcs15.0
VIT-011152Mon Nov 02, 2026 05:33 PMspo296.0room air
VIT-011153Mon Nov 02, 2026 05:33 PMrr15.0
VIT-011230Mon Nov 02, 2026 05:33 PMtemp_c36.6
VIT-011231Mon Nov 02, 2026 05:33 PMhr78.0
VIT-011232Mon Nov 02, 2026 05:33 PMmap88.0
VIT-011233Mon Nov 02, 2026 05:33 PMgcs15.0
VIT-011154Tue Nov 03, 2026 01:33 AMspo299.0room air
VIT-011155Tue Nov 03, 2026 01:33 AMrr20.0
VIT-011234Tue Nov 03, 2026 01:33 AMtemp_c37.5
VIT-011235Tue Nov 03, 2026 01:33 AMhr75.0
VIT-011236Tue Nov 03, 2026 01:33 AMmap78.0
VIT-011237Tue Nov 03, 2026 01:33 AMgcs15.0
VIT-011156Tue Nov 03, 2026 09:33 AMspo296.0room air
VIT-011157Tue Nov 03, 2026 09:33 AMrr20.0
VIT-011238Tue Nov 03, 2026 09:33 AMtemp_c37.4
VIT-011239Tue Nov 03, 2026 09:33 AMhr84.0
VIT-011240Tue Nov 03, 2026 09:33 AMmap75.0
VIT-011241Tue Nov 03, 2026 09:33 AMgcs15.0
VIT-011158Tue Nov 03, 2026 05:33 PMspo298.0room air
VIT-011159Tue Nov 03, 2026 05:33 PMrr16.0
VIT-011242Tue Nov 03, 2026 05:33 PMtemp_c37.4
VIT-011243Tue Nov 03, 2026 05:33 PMhr82.0
VIT-011244Tue Nov 03, 2026 05:33 PMmap87.0
VIT-011245Tue Nov 03, 2026 05:33 PMgcs15.0
VIT-011160Wed Nov 04, 2026 01:33 AMspo298.0room air
VIT-011161Wed Nov 04, 2026 01:33 AMrr15.0
VIT-011246Wed Nov 04, 2026 01:33 AMtemp_c36.5
VIT-011247Wed Nov 04, 2026 01:33 AMhr78.0
VIT-011248Wed Nov 04, 2026 01:33 AMmap89.0
VIT-011249Wed Nov 04, 2026 01:33 AMgcs15.0
VIT-011162Wed Nov 04, 2026 09:33 AMspo294.0room air
VIT-011163Wed Nov 04, 2026 09:33 AMrr14.0
VIT-011250Wed Nov 04, 2026 09:33 AMtemp_c37.1
VIT-011251Wed Nov 04, 2026 09:33 AMhr70.0
VIT-011252Wed Nov 04, 2026 09:33 AMmap86.0
VIT-011253Wed Nov 04, 2026 09:33 AMgcs15.0
VIT-011164Wed Nov 04, 2026 05:33 PMspo299.0room air
VIT-011165Wed Nov 04, 2026 05:33 PMrr16.0
VIT-011254Wed Nov 04, 2026 05:33 PMtemp_c37.6
VIT-011255Wed Nov 04, 2026 05:33 PMhr89.0
VIT-011256Wed Nov 04, 2026 05:33 PMmap77.0
VIT-011257Wed Nov 04, 2026 05:33 PMgcs15.0
VIT-011166Thu Nov 05, 2026 01:33 AMspo295.0room air
VIT-011167Thu Nov 05, 2026 01:33 AMrr16.0
VIT-011258Thu Nov 05, 2026 01:33 AMtemp_c37.1
VIT-011259Thu Nov 05, 2026 01:33 AMhr85.0
VIT-011260Thu Nov 05, 2026 01:33 AMmap87.0
VIT-011261Thu Nov 05, 2026 01:33 AMgcs15.0
VIT-011168Thu Nov 05, 2026 09:33 AMspo298.0room air
VIT-011169Thu Nov 05, 2026 09:33 AMrr16.0
VIT-011262Thu Nov 05, 2026 09:33 AMtemp_c36.7
VIT-011263Thu Nov 05, 2026 09:33 AMhr84.0
VIT-011264Thu Nov 05, 2026 09:33 AMmap86.0
VIT-011265Thu Nov 05, 2026 09:33 AMgcs15.0
Medications, orders, echo, history (4)

Notes

History and physical · DOC-000385 · Dr. Odette Galloway (attending) · Wed Oct 28, 2026 08:13 PM

Cited facts from this note (1)
infection_source
left lower lobe pneumonia · cited p. 1, line 5 · confidence 0.85
Show source for infection_source
… : Hospital Medicine Attending: Dr. Odette Galloway History of present illness: 54-year-old man admitted with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: hyperlipidemia, type 2 diabetes. Review of systems otherwise negative. Exam: Lungs: clear …
Source document DOC-000385: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Yusuf Whitlock   MRN: MRN46676005   Admitted: 2026-10-28 17:13
Service: Hospital Medicine   Attending: Dr. Odette Galloway

History of present illness: 54-year-old man admitted with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: hyperlipidemia, type 2 diabetes.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Nutrition assessment · DOC-000384 · Dario Larkspur, RD (dietitian) · Thu Oct 29, 2026 10:13 PM

Cited facts from this note (5)
fat_loss
none · cited p. 1, line 7 · confidence 0.90
Show source for fat_loss
… MRN: MRN46676005 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: Yusuf Whitlock MRN: MRN46676005 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: Yusuf Whitlock MRN: MRN46676005 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-000384: Nutrition assessment (synthetic)
NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Yusuf Whitlock   MRN: MRN46676005

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-000386 · Dr. Odette Galloway (attending) · Fri Oct 30, 2026 06:13 PM

Source document DOC-000386: Progress note (synthetic)
PROGRESS NOTE (Attending)
Patient: Yusuf Whitlock   MRN: MRN46676005   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. AKI: trend creatinine, hold nephrotoxins, strict intake and output.
3. Acute blood loss anemia: trend hemoglobin, transfuse if needed.

Attending: Dr. Odette Galloway

Discharge summary · DOC-000387 · Dr. Odette Galloway (attending) · Thu Nov 05, 2026 02:12 PM

Source document DOC-000387: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Yusuf Whitlock   MRN: MRN46676005
Admitted 2026-10-28; discharged 2026-11-05.

Discharge diagnoses:
- community-acquired pneumonia
- AKI
- acute blood loss anemia
- hyperlipidemia
- type 2 diabetes

Disposition: home with follow-up.