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-00118: Ines Stavros

52M · MRN96254353 · Hospital Medicine · admitted Sun Nov 08, 2026 03:51 PM · discharged Wed Nov 11, 2026 01:37 PM · attending Dr. Isaac Abernath · resident Dr. Camila Oyelaran · 176 cm, 82.9 kg

Documented diagnoses (current)

Principal: “upper GI bleed” · K92.2 Gastrointestinal hemorrhage, unspecified
“acute blood loss anemia” · D62 Acute posthemorrhagic anemia
“type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications

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

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=1.061, t.ratio_s1=1.5, creat_rise_48h=0.04, 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=1.22, 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=0.04, 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

No gap

Supported as documented (D62).

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=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=3.1, 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=215, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=78.2, egfr_late=76.6	78.2
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=78.2, t.g2=60, egfr_late=76.6	false
derived: category	`case(staging_egfr >= t.g2, 'G1-G2', staging_egfr >= t.g3a, 'G3a', staging_egfr >= t.g3b, 'G3b', staging_egfr >= t.g4, 'G4', 'G5')`	staging_egfr=78.2, 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=78.2, egfr_late=76.6, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=78.2, 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)
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=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)
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=136.0, t.profound=125, t.moderate=130, t.low=135	none
outcome: met	`na_min < t.low and na_low_count >= t.repeat and na_treated`	na_min=136.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=136.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=136.0, t.low=135	true

Malnutrition

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

Trace

Rule trace (rule malnutrition v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
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=unknown, t.a_sev_intake_pct=50, intake_days=unknown, t.a_sev_intake_days=5	unknown
derived: a_mod_intake	`intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days`	intake_pct=unknown, t.a_mod_intake_pct=75, intake_days=unknown, t.a_mod_intake_days=7	unknown
derived: a_sev_wt	`(wt_loss_days <= 7 and wt_loss_pct > 2) or (wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: a_mod_wt	`(wt_loss_days <= 7 and wt_loss_pct >= 1) or (wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: c_sev_intake	`intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=unknown, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30	unknown
derived: c_mod_intake	`intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=unknown, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30	unknown
derived: c_sev_wt	`(wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5) or (wt_loss_days <= 183 and wt_loss_pct > 10) or (wt_loss_days <= 366 and wt_loss_pct > 20)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: c_mod_wt	`(wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5) or (wt_loss_days <= 183 and wt_loss_pct >= 10) or (wt_loss_days <= 366 and wt_loss_pct >= 20)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: n_assessed	`known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced)`	intake_pct=unknown, wt_loss_pct=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown	0
derived: n_severe	`case(nutr_context == 'acute', count(a_sev_intake, a_sev_wt, fat_loss >= 2, muscle_loss >= 2, fluid >= 2, grip_reduced), nutr_context == 'chronic', count(c_sev_intake, c_sev_wt, fat_loss >= 3, muscle_loss >= 3, fluid >= 3, grip_reduced), null)`	nutr_context=unknown, a_sev_intake=unknown, a_sev_wt=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown, c_sev_intake=unknown, c_sev_wt=unknown	unknown
derived: n_moderate	`case(nutr_context == 'acute', count(a_sev_intake or a_mod_intake, a_sev_wt or a_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), nutr_context == 'chronic', count(c_sev_intake or c_mod_intake, c_sev_wt or c_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), null)`	nutr_context=unknown, a_sev_intake=unknown, a_mod_intake=unknown, a_sev_wt=unknown, a_mod_wt=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown, c_sev_intake=unknown, c_mod_intake=unknown, c_sev_wt=unknown, c_mod_wt=unknown	unknown
outcome: severe	`n_severe >= 2`	n_severe=unknown	unknown
outcome: moderate	`n_moderate >= 2`	n_moderate=unknown	unknown
outcome: one_characteristic	`n_moderate == 1`	n_moderate=unknown	unknown
outcome: not_met	`n_moderate == 0 and n_assessed >= 2`	n_moderate=unknown, n_assessed=0	false

Obesity

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule obesity v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
outcome: not_adult	`age < t.adult`	age=52, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=26.8, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=26.8, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=26.8, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=26.8, t.c1=30	true

Pressure injury

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

Trace

Rule trace (rule pressure_injury v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
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 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)
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=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)
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=37.4, t.t_hi=38, temp_min_48h=36.5, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=90.0, 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=9.73, t.wbc_hi=12, wbc_min_48h=6.91, 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=176.0	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=0.69	0
derived: sofa_cardio	`coalesce(case(norepi_max_48h > 0.1, 4, norepi_max_48h > 0, 3, map_min_48h < 70, 1, 0), 0)`	norepi_max_48h=0.0, map_min_48h=75.0	0
derived: sofa_cns	`coalesce(case(gcs_min_48h < 6, 4, gcs_min_48h < 10, 3, gcs_min_48h < 13, 2, gcs_min_48h < 15, 1, 0), 0)`	gcs_min_48h=15.0	0
derived: sofa_renal	`coalesce(case(creat_max_48h >= 5, 4, creat_max_48h >= 3.5, 3, creat_max_48h >= 2, 2, creat_max_48h >= 1.2, 1, 0), 0)`	creat_max_48h=1.18	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=1.15	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=False, sofa_delta=0, t.sofa_delta=2	false
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=False, sirs_count=0, t.sirs_min=2	false
derived: shock	`sepsis3 and norepi_max_48h > 0 and coalesce(lactate_max_48h > t.lactate, false)`	sepsis3=False, norepi_max_48h=0.0, lactate_max_48h=unknown, t.lactate=2	false
outcome: no_infection	`not infection_documented`	infection_documented=False	true

Structured data

Labs (23)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-004034	Sun Jan 04, 2026 09:15 AM	creatinine	1.13 mg/dL
LAB-004035	Sat Aug 08, 2026 10:05 AM	creatinine	1.15 mg/dL
LAB-004036	Sun Nov 08, 2026 04:51 PM	creatinine	1.16 mg/dL
LAB-004040	Sun Nov 08, 2026 04:51 PM	sodium	138.0 mmol/L
LAB-004044	Sun Nov 08, 2026 04:51 PM	hemoglobin	13.1 g/dL
LAB-004048	Sun Nov 08, 2026 04:51 PM	wbc	9.73 x10^3/uL
LAB-004049	Sun Nov 08, 2026 04:51 PM	platelets	176.0 x10^3/uL
LAB-004056	Sun Nov 08, 2026 04:51 PM	bilirubin	0.69 mg/dL
LAB-004037	Mon Nov 09, 2026 05:00 AM	creatinine	1.18 mg/dL
LAB-004041	Mon Nov 09, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-004045	Mon Nov 09, 2026 05:00 AM	hemoglobin	11.22 g/dL
LAB-004050	Mon Nov 09, 2026 05:00 AM	wbc	6.91 x10^3/uL
LAB-004051	Mon Nov 09, 2026 05:00 AM	platelets	237.0 x10^3/uL
LAB-004038	Tue Nov 10, 2026 05:00 AM	creatinine	1.18 mg/dL
LAB-004042	Tue Nov 10, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-004046	Tue Nov 10, 2026 05:00 AM	hemoglobin	9.96 g/dL
LAB-004052	Tue Nov 10, 2026 05:00 AM	wbc	8.79 x10^3/uL
LAB-004053	Tue Nov 10, 2026 05:00 AM	platelets	215.0 x10^3/uL
LAB-004039	Wed Nov 11, 2026 05:00 AM	creatinine	1.22 mg/dL
LAB-004043	Wed Nov 11, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-004047	Wed Nov 11, 2026 05:00 AM	hemoglobin	10.76 g/dL
LAB-004054	Wed Nov 11, 2026 05:00 AM	wbc	9.22 x10^3/uL
LAB-004055	Wed Nov 11, 2026 05:00 AM	platelets	171.0 x10^3/uL

Vitals (54)

Vitals
Row	When	Kind	Value	Detail
VIT-011580	Sun Nov 08, 2026 04:11 PM	spo2	95.0	room air
VIT-011581	Sun Nov 08, 2026 04:11 PM	rr	18.0
VIT-011598	Sun Nov 08, 2026 04:11 PM	temp_c	37.2
VIT-011599	Sun Nov 08, 2026 04:11 PM	hr	84.0
VIT-011600	Sun Nov 08, 2026 04:11 PM	map	84.0
VIT-011601	Sun Nov 08, 2026 04:11 PM	gcs	15.0
VIT-011582	Mon Nov 09, 2026 12:11 AM	spo2	98.0	room air
VIT-011583	Mon Nov 09, 2026 12:11 AM	rr	17.0
VIT-011602	Mon Nov 09, 2026 12:11 AM	temp_c	36.5
VIT-011603	Mon Nov 09, 2026 12:11 AM	hr	84.0
VIT-011604	Mon Nov 09, 2026 12:11 AM	map	91.0
VIT-011605	Mon Nov 09, 2026 12:11 AM	gcs	15.0
VIT-011584	Mon Nov 09, 2026 08:11 AM	spo2	96.0	room air
VIT-011585	Mon Nov 09, 2026 08:11 AM	rr	18.0
VIT-011606	Mon Nov 09, 2026 08:11 AM	temp_c	36.9
VIT-011607	Mon Nov 09, 2026 08:11 AM	hr	90.0
VIT-011608	Mon Nov 09, 2026 08:11 AM	map	81.0
VIT-011609	Mon Nov 09, 2026 08:11 AM	gcs	15.0
VIT-011586	Mon Nov 09, 2026 04:11 PM	spo2	94.0	room air
VIT-011587	Mon Nov 09, 2026 04:11 PM	rr	18.0
VIT-011610	Mon Nov 09, 2026 04:11 PM	temp_c	37.4
VIT-011611	Mon Nov 09, 2026 04:11 PM	hr	81.0
VIT-011612	Mon Nov 09, 2026 04:11 PM	map	88.0
VIT-011613	Mon Nov 09, 2026 04:11 PM	gcs	15.0
VIT-011588	Tue Nov 10, 2026 12:11 AM	spo2	94.0	room air
VIT-011589	Tue Nov 10, 2026 12:11 AM	rr	20.0
VIT-011614	Tue Nov 10, 2026 12:11 AM	temp_c	37.3
VIT-011615	Tue Nov 10, 2026 12:11 AM	hr	89.0
VIT-011616	Tue Nov 10, 2026 12:11 AM	map	87.0
VIT-011617	Tue Nov 10, 2026 12:11 AM	gcs	15.0
VIT-011590	Tue Nov 10, 2026 08:11 AM	spo2	95.0	room air
VIT-011591	Tue Nov 10, 2026 08:11 AM	rr	14.0
VIT-011618	Tue Nov 10, 2026 08:11 AM	temp_c	36.6
VIT-011619	Tue Nov 10, 2026 08:11 AM	hr	86.0
VIT-011620	Tue Nov 10, 2026 08:11 AM	map	75.0
VIT-011621	Tue Nov 10, 2026 08:11 AM	gcs	15.0
VIT-011592	Tue Nov 10, 2026 04:11 PM	spo2	99.0	room air
VIT-011593	Tue Nov 10, 2026 04:11 PM	rr	17.0
VIT-011622	Tue Nov 10, 2026 04:11 PM	temp_c	36.8
VIT-011623	Tue Nov 10, 2026 04:11 PM	hr	83.0
VIT-011624	Tue Nov 10, 2026 04:11 PM	map	91.0
VIT-011625	Tue Nov 10, 2026 04:11 PM	gcs	15.0
VIT-011594	Wed Nov 11, 2026 12:11 AM	spo2	94.0	room air
VIT-011595	Wed Nov 11, 2026 12:11 AM	rr	18.0
VIT-011626	Wed Nov 11, 2026 12:11 AM	temp_c	36.7
VIT-011627	Wed Nov 11, 2026 12:11 AM	hr	71.0
VIT-011628	Wed Nov 11, 2026 12:11 AM	map	88.0
VIT-011629	Wed Nov 11, 2026 12:11 AM	gcs	15.0
VIT-011596	Wed Nov 11, 2026 08:11 AM	spo2	95.0	room air
VIT-011597	Wed Nov 11, 2026 08:11 AM	rr	16.0
VIT-011630	Wed Nov 11, 2026 08:11 AM	temp_c	37.4
VIT-011631	Wed Nov 11, 2026 08:11 AM	hr	84.0
VIT-011632	Wed Nov 11, 2026 08:11 AM	map	89.0
VIT-011633	Wed Nov 11, 2026 08:11 AM	gcs	15.0

Medications, orders, echo, history (1)

ORD-000099 11-09 09:00 transfusion_prbc: transfuse PRBC

Notes

History and physical · DOC-000400 · Dr. Camila Oyelaran (resident) · Sun Nov 08, 2026 06:51 PM

Cited facts from this note (1)

bleeding_source: black tarry stools · cited p. 1, line 5 · confidence 0.85

Show source for bleeding_source

… rvice: Hospital Medicine Attending: Dr. Isaac Abernath History of present illness: 52-year-old man admitted with upper GI bleed. Presented after two days of black tarry stools; GI consulted for endoscopy. Past medical history: type 2 diabetes. Review of systems otherwise negative. Exam: Lungs: scattered crackles at the bases, no dist …

Source document DOC-000400: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Ines Stavros   MRN: MRN96254353   Admitted: 2026-11-08 15:51
Service: Hospital Medicine   Attending: Dr. Isaac Abernath

History of present illness: 52-year-old man admitted with upper GI bleed. Presented after two days of black tarry stools; GI consulted for endoscopy.
Past medical history: type 2 diabetes.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Upper GI bleed: PPI, GI following.

Progress note · DOC-000401 · Dr. Camila Oyelaran (resident) · Tue Nov 10, 2026 04:51 PM

Source document DOC-000401: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Ines Stavros   MRN: MRN96254353   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. Acute blood loss anemia: trend hemoglobin, transfuse if needed.

Resident: Dr. Camila Oyelaran   Attending cosign: completed

Discharge summary · DOC-000402 · Dr. Isaac Abernath (attending) · Wed Nov 11, 2026 01:37 PM

Source document DOC-000402: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Ines Stavros   MRN: MRN96254353
Admitted 2026-11-08; discharged 2026-11-11.

Discharge diagnoses:
- upper GI bleed
- acute blood loss anemia
- type 2 diabetes

Disposition: home with follow-up.