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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-00151: Dmitri Galloway

87F · MRN23383093 · General Surgery · admitted Tue Oct 27, 2026 07:35 PM · discharged Wed Nov 04, 2026 12:58 PM · attending Dr. Jalen Carrow · 159 cm, 78.2 kg

Documented diagnoses (current)

  • Principal: “upper GI bleed” · K92.2 Gastrointestinal hemorrhage, unspecified
  • “obesity” · E66.9 Obesity, unspecified
  • “acute kidney injury” · N17.9 Acute kidney failure, unspecified
  • “acute blood loss anemia” · D62 Acute posthemorrhagic anemia
  • “sacral pressure ulcer” · L89.159 Pressure ulcer of sacral region, unspecified stage
  • “hypertension” · I10 Essential (primary) hypertension
  • “hyperlipidemia” · E78.5 Hyperlipidemia, unspecified
  • “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

Every rule's outcome for this encounter (clean results included)
RuleCriteriaFindingOutcome
Acute kidney injury Criteria met No gap Supported as documented (N17.9).
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=2.553, t.ratio_s1=1.5, creat_rise_48h=0.27, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, t.uo_s1_h=6 true
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=True, creat_ratio=2.553, t.ratio_s3=3.0, creat_peak=1.2, 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=2.553, t.ratio_s2=2.0, uo_hours_lt_0_5=unknown, t.uo_s2_h=12 true
derived: stage case(stage3, 3, stage2, 2, meets_definition, 1, 0) stage3=False, stage2=True, meets_definition=True 2
derived: baseline_independent creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started creat_baseline_known=True, creat_rise_48h=0.27, t.rise_abs=0.3, rrt_started=False true
outcome: aki_staged stage >= 1 and baseline_independent stage=2, baseline_independent=True 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=F, hgb_nadir=10.35, 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=True, 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=338, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=91.6, egfr_late=92.1 92.1
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=91.6, t.g2=60, egfr_late=92.1 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=92.1, 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=91.6, egfr_late=92.1, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=92.1, 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 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)
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=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 met Specificity gap Documented “obesity” (E66.9); criteria support the more specific Obesity, class 1 (E66.811).
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=87, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=30.9, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=30.9, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=30.9, t.c1=30 true
Pressure injury Criteria met Specificity gap Documented “sacral pressure ulcer” (L89.159); criteria support the more specific Pressure injury of sacral region, stage 4 (L89.154).
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=sacral true
outcome: no_wound_note not present(wound_stage) wound_stage=4 false
outcome: other_site wound_site != 'sacral' wound_site=sacral false
outcome: stage1 sacral and wound_stage == '1' sacral=True, wound_stage=4 false
outcome: stage2 sacral and wound_stage == '2' sacral=True, wound_stage=4 false
outcome: stage3 sacral and wound_stage == '3' sacral=True, wound_stage=4 false
outcome: stage4 sacral and wound_stage == '4' sacral=True, wound_stage=4 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=36.6, t.t_lo=36 false
derived: sirs_hr coalesce(hr_max_48h > t.hr, false) hr_max_48h=81.0, 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=10.91, t.wbc_hi=12, wbc_min_48h=7.49, 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=213.0 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=0.96 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=77.0 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=1.2 1
derived: sofa_renal_baseline coalesce(case(creat_baseline >= 5, 4, creat_baseline >= 3.5, 3, creat_baseline >= 2, 2, creat_baseline >= 1.2, 1, 0), 0) creat_baseline=0.47 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=1, sofa_renal_baseline=0 1
derived: sepsis3 infection_documented and sofa_delta >= t.sofa_delta infection_documented=False, sofa_delta=1, 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 (48)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-005167Sat Oct 04, 2025 09:15 AMcreatinine0.48 mg/dL
LAB-005168Mon Sep 07, 2026 10:05 AMcreatinine0.47 mg/dL
LAB-005169Tue Oct 27, 2026 08:35 PMcreatinine0.93 mg/dL
LAB-005178Tue Oct 27, 2026 08:35 PMsodium136.0 mmol/L
LAB-005187Tue Oct 27, 2026 08:35 PMhemoglobin10.75 g/dL
LAB-005196Tue Oct 27, 2026 08:35 PMwbc7.49 x10^3/uL
LAB-005197Tue Oct 27, 2026 08:35 PMplatelets213.0 x10^3/uL
LAB-005214Tue Oct 27, 2026 08:35 PMbilirubin0.96 mg/dL
LAB-005170Wed Oct 28, 2026 05:00 AMcreatinine1.2 mg/dL
LAB-005179Wed Oct 28, 2026 05:00 AMsodium137.0 mmol/L
LAB-005188Wed Oct 28, 2026 05:00 AMhemoglobin10.35 g/dL
LAB-005198Wed Oct 28, 2026 05:00 AMwbc10.91 x10^3/uL
LAB-005199Wed Oct 28, 2026 05:00 AMplatelets215.0 x10^3/uL
LAB-005171Thu Oct 29, 2026 05:00 AMcreatinine1.08 mg/dL
LAB-005180Thu Oct 29, 2026 05:00 AMsodium142.0 mmol/L
LAB-005189Thu Oct 29, 2026 05:00 AMhemoglobin10.75 g/dL
LAB-005200Thu Oct 29, 2026 05:00 AMwbc10.86 x10^3/uL
LAB-005201Thu Oct 29, 2026 05:00 AMplatelets280.0 x10^3/uL
LAB-005172Fri Oct 30, 2026 05:00 AMcreatinine0.9 mg/dL
LAB-005181Fri Oct 30, 2026 05:00 AMsodium137.0 mmol/L
LAB-005190Fri Oct 30, 2026 05:00 AMhemoglobin10.35 g/dL
LAB-005202Fri Oct 30, 2026 05:00 AMwbc9.94 x10^3/uL
LAB-005203Fri Oct 30, 2026 05:00 AMplatelets186.0 x10^3/uL
LAB-005173Sat Oct 31, 2026 05:00 AMcreatinine0.74 mg/dL
LAB-005182Sat Oct 31, 2026 05:00 AMsodium139.0 mmol/L
LAB-005191Sat Oct 31, 2026 05:00 AMhemoglobin10.75 g/dL
LAB-005204Sat Oct 31, 2026 05:00 AMwbc9.91 x10^3/uL
LAB-005205Sat Oct 31, 2026 05:00 AMplatelets282.0 x10^3/uL
LAB-005174Sun Nov 01, 2026 05:00 AMcreatinine0.66 mg/dL
LAB-005183Sun Nov 01, 2026 05:00 AMsodium140.0 mmol/L
LAB-005192Sun Nov 01, 2026 05:00 AMhemoglobin10.35 g/dL
LAB-005206Sun Nov 01, 2026 05:00 AMwbc7.4 x10^3/uL
LAB-005207Sun Nov 01, 2026 05:00 AMplatelets183.0 x10^3/uL
LAB-005175Mon Nov 02, 2026 05:00 AMcreatinine0.6 mg/dL
LAB-005184Mon Nov 02, 2026 05:00 AMsodium141.0 mmol/L
LAB-005193Mon Nov 02, 2026 05:00 AMhemoglobin10.75 g/dL
LAB-005208Mon Nov 02, 2026 05:00 AMwbc5.76 x10^3/uL
LAB-005209Mon Nov 02, 2026 05:00 AMplatelets238.0 x10^3/uL
LAB-005176Tue Nov 03, 2026 05:00 AMcreatinine0.57 mg/dL
LAB-005185Tue Nov 03, 2026 05:00 AMsodium136.0 mmol/L
LAB-005194Tue Nov 03, 2026 05:00 AMhemoglobin10.35 g/dL
LAB-005210Tue Nov 03, 2026 05:00 AMwbc6.48 x10^3/uL
LAB-005211Tue Nov 03, 2026 05:00 AMplatelets170.0 x10^3/uL
LAB-005177Wed Nov 04, 2026 05:00 AMcreatinine0.56 mg/dL
LAB-005186Wed Nov 04, 2026 05:00 AMsodium142.0 mmol/L
LAB-005195Wed Nov 04, 2026 05:00 AMhemoglobin10.75 g/dL
LAB-005212Wed Nov 04, 2026 05:00 AMwbc9.79 x10^3/uL
LAB-005213Wed Nov 04, 2026 05:00 AMplatelets274.0 x10^3/uL
Vitals (144)
Vitals
RowWhenKindValueDetail
VIT-014867Tue Oct 27, 2026 07:55 PMspo297.0room air
VIT-014868Tue Oct 27, 2026 07:55 PMrr14.0
VIT-014915Tue Oct 27, 2026 07:55 PMtemp_c37.6
VIT-014916Tue Oct 27, 2026 07:55 PMhr76.0
VIT-014917Tue Oct 27, 2026 07:55 PMmap79.0
VIT-014918Tue Oct 27, 2026 07:55 PMgcs15.0
VIT-014869Wed Oct 28, 2026 03:55 AMspo296.0room air
VIT-014870Wed Oct 28, 2026 03:55 AMrr17.0
VIT-014919Wed Oct 28, 2026 03:55 AMtemp_c37.0
VIT-014920Wed Oct 28, 2026 03:55 AMhr73.0
VIT-014921Wed Oct 28, 2026 03:55 AMmap86.0
VIT-014922Wed Oct 28, 2026 03:55 AMgcs15.0
VIT-014871Wed Oct 28, 2026 11:55 AMspo296.0room air
VIT-014872Wed Oct 28, 2026 11:55 AMrr20.0
VIT-014923Wed Oct 28, 2026 11:55 AMtemp_c36.6
VIT-014924Wed Oct 28, 2026 11:55 AMhr81.0
VIT-014925Wed Oct 28, 2026 11:55 AMmap91.0
VIT-014926Wed Oct 28, 2026 11:55 AMgcs15.0
VIT-014873Wed Oct 28, 2026 07:55 PMspo297.0room air
VIT-014874Wed Oct 28, 2026 07:55 PMrr18.0
VIT-014927Wed Oct 28, 2026 07:55 PMtemp_c36.9
VIT-014928Wed Oct 28, 2026 07:55 PMhr68.0
VIT-014929Wed Oct 28, 2026 07:55 PMmap91.0
VIT-014930Wed Oct 28, 2026 07:55 PMgcs15.0
VIT-014875Thu Oct 29, 2026 03:55 AMspo298.0room air
VIT-014876Thu Oct 29, 2026 03:55 AMrr16.0
VIT-014931Thu Oct 29, 2026 03:55 AMtemp_c36.6
VIT-014932Thu Oct 29, 2026 03:55 AMhr70.0
VIT-014933Thu Oct 29, 2026 03:55 AMmap77.0
VIT-014934Thu Oct 29, 2026 03:55 AMgcs15.0
VIT-014877Thu Oct 29, 2026 11:55 AMspo297.0room air
VIT-014878Thu Oct 29, 2026 11:55 AMrr17.0
VIT-014935Thu Oct 29, 2026 11:55 AMtemp_c37.4
VIT-014936Thu Oct 29, 2026 11:55 AMhr81.0
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VIT-014905Tue Nov 03, 2026 03:55 AMspo298.0room air
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VIT-015007Wed Nov 04, 2026 11:55 AMtemp_c37.4
VIT-015008Wed Nov 04, 2026 11:55 AMhr85.0
VIT-015009Wed Nov 04, 2026 11:55 AMmap92.0
VIT-015010Wed Nov 04, 2026 11:55 AMgcs15.0
Medications, orders, echo, history (0)

Notes

History and physical · DOC-000511 · Dr. Jalen Carrow (attending) · Tue Oct 27, 2026 10:35 PM

Cited facts from this note (1)
bleeding_source
hematemesis · cited p. 1, line 5 · confidence 0.85
Show source for bleeding_source
… Service: General Surgery Attending: Dr. Jalen Carrow History of present illness: 87-year-old woman admitted with upper GI bleed. Presented after two days of hematemesis; GI consulted for endoscopy. Past medical history: hypertension, hyperlipidemia, GERD. Review of systems otherwise negative. Exam: Lungs: scattered crackles at …
Source document DOC-000511: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Dmitri Galloway   MRN: MRN23383093   Admitted: 2026-10-27 19:35
Service: General Surgery   Attending: Dr. Jalen Carrow

History of present illness: 87-year-old woman admitted with upper GI bleed. Presented after two days of hematemesis; GI consulted for endoscopy.
Past medical history: hypertension, hyperlipidemia, GERD.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Upper GI bleed: PPI, GI following.

Wound care note · DOC-000510 · Elena Jessup, RN, CWOCN (wound_nurse) · Thu Oct 29, 2026 01:35 AM

Cited facts from this note (2)
wound_site
sacral · cited p. 1, line 4 · confidence 0.95
Show source for wound_site
WOUND CARE NOTE Patient: Dmitri Galloway MRN: MRN23383093 Location: sacrum Stage: 4 (NPIAP) Description: full-thickness tissue loss with palpable bone. Size: 3.3 x 3.3 x 0.4 cm. Plan: offloading every 2 hours, foam dressing, nutrition …
wound_stage
4 · cited p. 1, line 5 · confidence 0.95
Show source for wound_stage
WOUND CARE NOTE Patient: Dmitri Galloway MRN: MRN23383093 Location: sacrum Stage: 4 (NPIAP) Description: full-thickness tissue loss with palpable bone. Size: 3.3 x 3.3 x 0.4 cm. Plan: offloading every 2 hours, foam dressing, nutrition consult.
Source document DOC-000510: Wound care note (synthetic)
WOUND CARE NOTE
Patient: Dmitri Galloway   MRN: MRN23383093

Location: sacrum
Stage: 4 (NPIAP)
Description: full-thickness tissue loss with palpable bone.
Size: 3.3 x 3.3 x 0.4 cm.
Plan: offloading every 2 hours, foam dressing, nutrition consult.

Progress note · DOC-000512 · Dr. Jalen Carrow (attending) · Thu Oct 29, 2026 11:35 PM

Source document DOC-000512: Progress note (synthetic)
PROGRESS NOTE (Attending)
Patient: Dmitri Galloway   MRN: MRN23383093   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. Obesity: counsel on weight.
3. Acute kidney injury: trend creatinine, hold nephrotoxins, strict intake and output.
4. Acute blood loss anemia: trend hemoglobin, transfuse if needed.
5. Sacral pressure ulcer: wound care following, offloading.

Attending: Dr. Jalen Carrow

Discharge summary · DOC-000513 · Dr. Jalen Carrow (attending) · Wed Nov 04, 2026 12:58 PM

Source document DOC-000513: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Dmitri Galloway   MRN: MRN23383093
Admitted 2026-10-27; discharged 2026-11-04.

Discharge diagnoses:
- upper GI bleed
- obesity
- acute kidney injury
- acute blood loss anemia
- sacral pressure ulcer
- hypertension
- hyperlipidemia
- GERD

Disposition: home with follow-up.