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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-00130: Nico Bellweather

72M · MRN20732779 · Hospital Medicine · admitted Tue Oct 27, 2026 08:56 PM · discharged Tue Nov 03, 2026 12:32 PM · attending Dr. Kenji Stavros · resident Dr. Camila Oyelaran · 181 cm, 70.9 kg

Documented diagnoses (current)

  • Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
  • “severe protein-calorie malnutrition” · E43 Unspecified severe protein-calorie malnutrition
  • “hyperlipidemia” · E78.5 Hyperlipidemia, unspecified
  • “hypertension” · I10 Essential (primary) hypertension
  • “GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis

Illustrative grouping now: MS-DRG 193 Simple pneumonia and pleurisy with MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 194.

Queries and events

No queries yet.

All rules applied

Every rule's outcome for this encounter (clean results included)
RuleCriteriaFindingOutcome
Acute kidney injury Criteria 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=1.05, 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=1.05, t.ratio_s3=3.0, creat_peak=1.06, 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=1.05, 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 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)
StepExpressionInputs and thresholds readResult
derived: anaemic case(sex == 'M', hgb_nadir < t.hb_m, sex == 'F', hgb_nadir < t.hb_f, null) sex=M, hgb_nadir=9.67, t.hb_m=13, t.hb_f=12 true
derived: acute_fall hgb_drop >= t.drop_major or prbc_units >= t.prbc_major hgb_drop=3.5, t.drop_major=2.0, prbc_units=2, t.prbc_major=2 true
outcome: met bleeding_documented and anaemic and acute_fall bleeding_documented=True, anaemic=True, acute_fall=True true
Chronic kidney disease 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=239, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=80.0, egfr_late=79.0 80.0
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=80.0, t.g2=60, egfr_late=79.0 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=80.0, 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=80.0, egfr_late=79.0, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=80.0, 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 met Clinical validation gap Documented “severe protein-calorie malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (acute illness context), E44.0).
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=60.0, t.a_sev_intake_pct=50, intake_days=11.0, 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=60.0, t.a_mod_intake_pct=75, intake_days=11.0, t.a_mod_intake_days=7 true
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=3.0 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=3.0 false
derived: c_sev_intake intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days intake_pct=60.0, t.c_intake_pct=75, intake_days=11.0, 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=60.0, t.c_intake_pct=75, intake_days=11.0, 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=3.0 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=3.0 false
derived: n_assessed known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced) intake_pct=60.0, wt_loss_pct=3.0, 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=acute, 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=acute, a_sev_intake=False, a_mod_intake=True, a_sev_wt=False, a_mod_wt=False, 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=False 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)
StepExpressionInputs and thresholds readResult
outcome: not_adult age < t.adult age=72, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=21.6, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=21.6, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=21.6, t.c1=30 false
outcome: not_met bmi < t.c1 bmi=21.6, t.c1=30 true
Pressure injury Insufficient data No gap Insufficient data: the criteria could not be applied.
Trace
Rule trace (rule pressure_injury v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
StepExpressionInputs and thresholds readResult
derived: sacral wound_site == 'sacral' wound_site=unknown unknown
outcome: no_wound_note not present(wound_stage) wound_stage=unknown true
Acute respiratory failure Criteria not met No gap Not documented and not supported.
Trace
Rule trace (rule respiratory_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
StepExpressionInputs and thresholds readResult
derived: measured present(spo2_min_ra) or present(pao2_min_ra) or present(pf_min) spo2_min_ra=94.0, pao2_min_ra=unknown, pf_min=unknown true
derived: hypoxemia coalesce(spo2_min_ra < t.spo2_ra, false) or coalesce(pao2_min_ra < t.pao2, false) or coalesce(pf_min < t.pf, false) spo2_min_ra=94.0, t.spo2_ra=88, pao2_min_ra=unknown, t.pao2=60, pf_min=unknown, t.pf=300 false
derived: distress coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support rr_max=20.0, t.rr_distress=28, wob_increased=unknown, adv_resp_support=False false
outcome: chronic_baseline home_o2 and hypoxemia home_o2=False, hypoxemia=False false
outcome: met hypoxemia and distress hypoxemia=False, distress=False false
outcome: hypoxemia_only hypoxemia hypoxemia=False false
outcome: not_met measured and not hypoxemia and o2_max_lpm <= t.o2_low and not adv_resp_support measured=True, hypoxemia=False, o2_max_lpm=0.0, t.o2_low=2, adv_resp_support=False true
Sepsis Criteria 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=37.6, 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=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=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=10.26, t.wbc_hi=12, wbc_min_48h=7.32, 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=189.0 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=0.84 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=1.06 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=1.01 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 (43)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-004421Wed Dec 31, 2025 09:15 AMcreatinine1.0 mg/dL
LAB-004422Fri Aug 28, 2026 10:05 AMcreatinine1.01 mg/dL
LAB-004423Tue Oct 27, 2026 09:56 PMcreatinine1.05 mg/dL
LAB-004431Tue Oct 27, 2026 09:56 PMsodium140.0 mmol/L
LAB-004439Tue Oct 27, 2026 09:56 PMhemoglobin13.16 g/dL
LAB-004447Tue Oct 27, 2026 09:56 PMwbc10.26 x10^3/uL
LAB-004448Tue Oct 27, 2026 09:56 PMplatelets209.0 x10^3/uL
LAB-004463Tue Oct 27, 2026 09:56 PMbilirubin0.84 mg/dL
LAB-004424Wed Oct 28, 2026 05:00 AMcreatinine1.04 mg/dL
LAB-004432Wed Oct 28, 2026 05:00 AMsodium142.0 mmol/L
LAB-004440Wed Oct 28, 2026 05:00 AMhemoglobin11.06 g/dL
LAB-004449Wed Oct 28, 2026 05:00 AMwbc7.32 x10^3/uL
LAB-004450Wed Oct 28, 2026 05:00 AMplatelets189.0 x10^3/uL
LAB-004425Thu Oct 29, 2026 05:00 AMcreatinine1.06 mg/dL
LAB-004433Thu Oct 29, 2026 05:00 AMsodium140.0 mmol/L
LAB-004441Thu Oct 29, 2026 05:00 AMhemoglobin9.67 g/dL
LAB-004451Thu Oct 29, 2026 05:00 AMwbc7.88 x10^3/uL
LAB-004452Thu Oct 29, 2026 05:00 AMplatelets285.0 x10^3/uL
LAB-004426Fri Oct 30, 2026 05:00 AMcreatinine1.02 mg/dL
LAB-004434Fri Oct 30, 2026 05:00 AMsodium142.0 mmol/L
LAB-004442Fri Oct 30, 2026 05:00 AMhemoglobin10.47 g/dL
LAB-004453Fri Oct 30, 2026 05:00 AMwbc7.85 x10^3/uL
LAB-004454Fri Oct 30, 2026 05:00 AMplatelets282.0 x10^3/uL
LAB-004427Sat Oct 31, 2026 05:00 AMcreatinine1.01 mg/dL
LAB-004435Sat Oct 31, 2026 05:00 AMsodium140.0 mmol/L
LAB-004443Sat Oct 31, 2026 05:00 AMhemoglobin10.77 g/dL
LAB-004455Sat Oct 31, 2026 05:00 AMwbc9.61 x10^3/uL
LAB-004456Sat Oct 31, 2026 05:00 AMplatelets300.0 x10^3/uL
LAB-004428Sun Nov 01, 2026 05:00 AMcreatinine1.05 mg/dL
LAB-004436Sun Nov 01, 2026 05:00 AMsodium136.0 mmol/L
LAB-004444Sun Nov 01, 2026 05:00 AMhemoglobin10.87 g/dL
LAB-004457Sun Nov 01, 2026 05:00 AMwbc9.22 x10^3/uL
LAB-004458Sun Nov 01, 2026 05:00 AMplatelets226.0 x10^3/uL
LAB-004429Mon Nov 02, 2026 05:00 AMcreatinine1.05 mg/dL
LAB-004437Mon Nov 02, 2026 05:00 AMsodium141.0 mmol/L
LAB-004445Mon Nov 02, 2026 05:00 AMhemoglobin10.87 g/dL
LAB-004459Mon Nov 02, 2026 05:00 AMwbc9.93 x10^3/uL
LAB-004460Mon Nov 02, 2026 05:00 AMplatelets304.0 x10^3/uL
LAB-004430Tue Nov 03, 2026 05:00 AMcreatinine1.0 mg/dL
LAB-004438Tue Nov 03, 2026 05:00 AMsodium141.0 mmol/L
LAB-004446Tue Nov 03, 2026 05:00 AMhemoglobin10.87 g/dL
LAB-004461Tue Nov 03, 2026 05:00 AMwbc6.07 x10^3/uL
LAB-004462Tue Nov 03, 2026 05:00 AMplatelets228.0 x10^3/uL
Vitals (120)
Vitals
RowWhenKindValueDetail
VIT-012695Tue Oct 27, 2026 09:16 PMspo295.0room air
VIT-012696Tue Oct 27, 2026 09:16 PMrr15.0
VIT-012735Tue Oct 27, 2026 09:16 PMtemp_c36.5
VIT-012736Tue Oct 27, 2026 09:16 PMhr87.0
VIT-012737Tue Oct 27, 2026 09:16 PMmap86.0
VIT-012738Tue Oct 27, 2026 09:16 PMgcs15.0
VIT-012697Wed Oct 28, 2026 05:16 AMspo298.0room air
VIT-012698Wed Oct 28, 2026 05:16 AMrr18.0
VIT-012739Wed Oct 28, 2026 05:16 AMtemp_c36.5
VIT-012740Wed Oct 28, 2026 05:16 AMhr88.0
VIT-012741Wed Oct 28, 2026 05:16 AMmap87.0
VIT-012742Wed Oct 28, 2026 05:16 AMgcs15.0
VIT-012699Wed Oct 28, 2026 01:16 PMspo294.0room air
VIT-012700Wed Oct 28, 2026 01:16 PMrr20.0
VIT-012743Wed Oct 28, 2026 01:16 PMtemp_c37.6
VIT-012744Wed Oct 28, 2026 01:16 PMhr71.0
VIT-012745Wed Oct 28, 2026 01:16 PMmap83.0
VIT-012746Wed Oct 28, 2026 01:16 PMgcs15.0
VIT-012701Wed Oct 28, 2026 09:16 PMspo298.0room air
VIT-012702Wed Oct 28, 2026 09:16 PMrr15.0
VIT-012747Wed Oct 28, 2026 09:16 PMtemp_c37.0
VIT-012748Wed Oct 28, 2026 09:16 PMhr81.0
VIT-012749Wed Oct 28, 2026 09:16 PMmap75.0
VIT-012750Wed Oct 28, 2026 09:16 PMgcs15.0
VIT-012703Thu Oct 29, 2026 05:16 AMspo296.0room air
VIT-012704Thu Oct 29, 2026 05:16 AMrr17.0
VIT-012751Thu Oct 29, 2026 05:16 AMtemp_c37.2
VIT-012752Thu Oct 29, 2026 05:16 AMhr87.0
VIT-012753Thu Oct 29, 2026 05:16 AMmap75.0
VIT-012754Thu Oct 29, 2026 05:16 AMgcs15.0
VIT-012705Thu Oct 29, 2026 01:16 PMspo296.0room air
VIT-012706Thu Oct 29, 2026 01:16 PMrr15.0
VIT-012755Thu Oct 29, 2026 01:16 PMtemp_c37.5
VIT-012756Thu Oct 29, 2026 01:16 PMhr70.0
VIT-012757Thu Oct 29, 2026 01:16 PMmap81.0
VIT-012758Thu Oct 29, 2026 01:16 PMgcs15.0
VIT-012707Thu Oct 29, 2026 09:16 PMspo296.0room air
VIT-012708Thu Oct 29, 2026 09:16 PMrr18.0
VIT-012759Thu Oct 29, 2026 09:16 PMtemp_c36.6
VIT-012760Thu Oct 29, 2026 09:16 PMhr76.0
VIT-012761Thu Oct 29, 2026 09:16 PMmap83.0
VIT-012762Thu Oct 29, 2026 09:16 PMgcs15.0
VIT-012709Fri Oct 30, 2026 05:16 AMspo297.0room air
VIT-012710Fri Oct 30, 2026 05:16 AMrr15.0
VIT-012763Fri Oct 30, 2026 05:16 AMtemp_c37.5
VIT-012764Fri Oct 30, 2026 05:16 AMhr75.0
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VIT-012770Fri Oct 30, 2026 01:16 PMgcs15.0
VIT-012713Fri Oct 30, 2026 09:16 PMspo299.0room air
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VIT-012771Fri Oct 30, 2026 09:16 PMtemp_c37.1
VIT-012772Fri Oct 30, 2026 09:16 PMhr74.0
VIT-012773Fri Oct 30, 2026 09:16 PMmap74.0
VIT-012774Fri Oct 30, 2026 09:16 PMgcs15.0
VIT-012715Sat Oct 31, 2026 05:16 AMspo295.0room air
VIT-012716Sat Oct 31, 2026 05:16 AMrr17.0
VIT-012775Sat Oct 31, 2026 05:16 AMtemp_c36.6
VIT-012776Sat Oct 31, 2026 05:16 AMhr79.0
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VIT-012778Sat Oct 31, 2026 05:16 AMgcs15.0
VIT-012717Sat Oct 31, 2026 01:16 PMspo295.0room air
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VIT-012779Sat Oct 31, 2026 01:16 PMtemp_c37.0
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VIT-012719Sat Oct 31, 2026 09:16 PMspo294.0room air
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VIT-012783Sat Oct 31, 2026 09:16 PMtemp_c37.2
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VIT-012721Sun Nov 01, 2026 05:16 AMspo294.0room air
VIT-012722Sun Nov 01, 2026 05:16 AMrr18.0
VIT-012787Sun Nov 01, 2026 05:16 AMtemp_c37.0
VIT-012788Sun Nov 01, 2026 05:16 AMhr75.0
VIT-012789Sun Nov 01, 2026 05:16 AMmap75.0
VIT-012790Sun Nov 01, 2026 05:16 AMgcs15.0
VIT-012723Sun Nov 01, 2026 01:16 PMspo294.0room air
VIT-012724Sun Nov 01, 2026 01:16 PMrr20.0
VIT-012791Sun Nov 01, 2026 01:16 PMtemp_c36.7
VIT-012792Sun Nov 01, 2026 01:16 PMhr80.0
VIT-012793Sun Nov 01, 2026 01:16 PMmap91.0
VIT-012794Sun Nov 01, 2026 01:16 PMgcs15.0
VIT-012725Sun Nov 01, 2026 09:16 PMspo296.0room air
VIT-012726Sun Nov 01, 2026 09:16 PMrr17.0
VIT-012795Sun Nov 01, 2026 09:16 PMtemp_c37.0
VIT-012796Sun Nov 01, 2026 09:16 PMhr83.0
VIT-012797Sun Nov 01, 2026 09:16 PMmap84.0
VIT-012798Sun Nov 01, 2026 09:16 PMgcs15.0
VIT-012727Mon Nov 02, 2026 05:16 AMspo297.0room air
VIT-012728Mon Nov 02, 2026 05:16 AMrr18.0
VIT-012799Mon Nov 02, 2026 05:16 AMtemp_c37.5
VIT-012800Mon Nov 02, 2026 05:16 AMhr86.0
VIT-012801Mon Nov 02, 2026 05:16 AMmap82.0
VIT-012802Mon Nov 02, 2026 05:16 AMgcs15.0
VIT-012729Mon Nov 02, 2026 01:16 PMspo299.0room air
VIT-012730Mon Nov 02, 2026 01:16 PMrr17.0
VIT-012803Mon Nov 02, 2026 01:16 PMtemp_c37.0
VIT-012804Mon Nov 02, 2026 01:16 PMhr75.0
VIT-012805Mon Nov 02, 2026 01:16 PMmap82.0
VIT-012806Mon Nov 02, 2026 01:16 PMgcs15.0
VIT-012731Mon Nov 02, 2026 09:16 PMspo298.0room air
VIT-012732Mon Nov 02, 2026 09:16 PMrr20.0
VIT-012807Mon Nov 02, 2026 09:16 PMtemp_c37.5
VIT-012808Mon Nov 02, 2026 09:16 PMhr89.0
VIT-012809Mon Nov 02, 2026 09:16 PMmap80.0
VIT-012810Mon Nov 02, 2026 09:16 PMgcs15.0
VIT-012733Tue Nov 03, 2026 05:16 AMspo295.0room air
VIT-012734Tue Nov 03, 2026 05:16 AMrr15.0
VIT-012811Tue Nov 03, 2026 05:16 AMtemp_c37.0
VIT-012812Tue Nov 03, 2026 05:16 AMhr81.0
VIT-012813Tue Nov 03, 2026 05:16 AMmap84.0
VIT-012814Tue Nov 03, 2026 05:16 AMgcs15.0
Medications, orders, echo, history (5)

Notes

History and physical · DOC-000439 · Dr. Camila Oyelaran (resident) · Tue Oct 27, 2026 11:56 PM

Cited facts from this note (2)
bleeding_source
bleeding from the surgical drain · cited p. 1, line 5 · confidence 0.85
Show source for bleeding_source
… dmitted with community-acquired pneumonia. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Hospital course complicated by bleeding from the surgical drain. Past medical history: hyperlipidemia, hypertension, GERD. Review of systems otherwise negative. Exam: Lungs: scattered crackles at the bases, no distress. Ass …
infection_source
multifocal pneumonia · cited p. 1, line 5 · confidence 0.85
Show source for infection_source
… ce: Hospital Medicine Attending: Dr. Kenji Stavros History of present illness: 72-year-old man admitted with community-acquired pneumonia. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Hospital course complicated by bleeding from the surgical drain. Past medical history: hyperlipidemia, hypertens …
Source document DOC-000439: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Nico Bellweather   MRN: MRN20732779   Admitted: 2026-10-27 20:56
Service: Hospital Medicine   Attending: Dr. Kenji Stavros

History of present illness: 72-year-old man admitted with community-acquired pneumonia. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Hospital course complicated by bleeding from the surgical drain.
Past medical history: hyperlipidemia, hypertension, GERD.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Nutrition assessment · DOC-000438 · Viggo Ravensworth, RD (dietitian) · Thu Oct 29, 2026 12:56 AM

Cited facts from this note (8)
fat_loss
mild · cited p. 1, line 7 · confidence 0.90
Show source for fat_loss
… Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets criteria for non-severe (moderate) malnutrition.
fluid_accumulation
none · cited p. 1, line 7 · confidence 0.90
Show source for fluid_accumulation
… ake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets criteria for non-severe (moderate) malnutrition.
intake_days
11 · cited p. 1, line 5 · confidence 0.95
Show source for intake_days
NUTRITION ASSESSMENT (Registered Dietitian) Patient: Nico Bellweather MRN: MRN20732779 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip …
intake_pct
60 · cited p. 1, line 5 · confidence 0.95
Show source for intake_pct
NUTRITION ASSESSMENT (Registered Dietitian) Patient: Nico Bellweather MRN: MRN20732779 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip …
muscle_loss
mild · cited p. 1, line 7 · confidence 0.90
Show source for muscle_loss
… estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets criteria for non-severe (moderate) malnutrition.
nutrition_context
acute · cited p. 1, line 4 · confidence 0.95
Show source for nutrition_context
NUTRITION ASSESSMENT (Registered Dietitian) Patient: Nico Bellweather MRN: MRN20732779 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneo …
weight_loss_days
30 · cited p. 1, line 6 · confidence 0.95
Show source for weight_loss_days
… tered Dietitian) Patient: Nico Bellweather MRN: MRN20732779 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets cri …
weight_loss_pct
3 · cited p. 1, line 6 · confidence 0.95
Show source for weight_loss_pct
… tered Dietitian) Patient: Nico Bellweather MRN: MRN20732779 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: 3% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Grip strength: not assessed. Assessment: meets cri …
Source document DOC-000438: Nutrition assessment (synthetic)
NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Nico Bellweather   MRN: MRN20732779

Context: acute illness
Intake: estimated energy intake 60% of needs for 11 days.
Weight history: 3% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Grip strength: not assessed.
Assessment: meets criteria for non-severe (moderate) malnutrition.

Progress note · DOC-000440 · Dr. Camila Oyelaran (resident) · Thu Oct 29, 2026 11:56 PM

Source document DOC-000440: Progress note (synthetic)
PROGRESS NOTE (Resident)
Patient: Nico Bellweather   MRN: MRN20732779   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. Severe protein-calorie malnutrition: dietitian following, supplements.

Resident: Dr. Camila Oyelaran   Attending cosign: completed

Discharge summary · DOC-000441 · Dr. Kenji Stavros (attending) · Tue Nov 03, 2026 12:32 PM

Source document DOC-000441: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Nico Bellweather   MRN: MRN20732779
Admitted 2026-10-27; discharged 2026-11-03.

Discharge diagnoses:
- community-acquired pneumonia
- severe protein-calorie malnutrition
- hyperlipidemia
- hypertension
- GERD

Disposition: home with follow-up.