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-00160: Greta Nakashima

80F · MRN13032350 · Hospital Medicine · admitted Fri Oct 30, 2026 09:06 AM · discharged Fri Nov 06, 2026 10:56 AM · attending Dr. Isaac Abernath · resident Dr. Elena Nakashima · 170 cm, 79.7 kg

Documented diagnoses (current)

  • Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism

Illustrative grouping now: MS-DRG 195 Simple pneumonia and pleurisy without CC/MCC. 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 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=1.056, 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=1.056, t.ratio_s3=3.0, creat_peak=0.75, 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=1.056, 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 not met No gap Not documented and not supported.
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=12.56, t.hb_m=13, t.hb_f=12 false
derived: acute_fall hgb_drop >= t.drop_major or prbc_units >= t.prbc_major hgb_drop=0.6, 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=False, acute_fall=False false
outcome: anaemia_only anaemic and hgb_drop < t.drop_min and prbc_units == 0 anaemic=False, hgb_drop=0.6, t.drop_min=1.0, prbc_units=0 false
outcome: not_anaemic present(hgb_nadir) and not anaemic hgb_nadir=12.56, anaemic=False 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=193, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=84.5, egfr_late=85.9 85.9
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=84.5, t.g2=60, egfr_late=85.9 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=85.9, 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=84.5, egfr_late=85.9, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=85.9, 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 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=80, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=27.6, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=27.6, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=27.6, t.c1=30 false
outcome: not_met bmi < t.c1 bmi=27.6, 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=37.4, t.t_hi=38, temp_min_48h=36.9, 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=8.89, t.wbc_hi=12, wbc_min_48h=6.76, 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=203.0 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=0.64 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=0.75 0
derived: sofa_renal_baseline coalesce(case(creat_baseline >= 5, 4, creat_baseline >= 3.5, 3, creat_baseline >= 2, 2, creat_baseline >= 1.2, 1, 0), 0) creat_baseline=0.71 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-005447Sat Jan 17, 2026 09:15 AMcreatinine0.72 mg/dL
LAB-005448Thu Jul 30, 2026 10:05 AMcreatinine0.71 mg/dL
LAB-005449Fri Oct 30, 2026 10:06 AMcreatinine0.75 mg/dL
LAB-005457Fri Oct 30, 2026 10:06 AMsodium142.0 mmol/L
LAB-005465Fri Oct 30, 2026 10:06 AMhemoglobin12.93 g/dL
LAB-005473Fri Oct 30, 2026 10:06 AMwbc6.76 x10^3/uL
LAB-005474Fri Oct 30, 2026 10:06 AMplatelets203.0 x10^3/uL
LAB-005489Fri Oct 30, 2026 10:06 AMbilirubin0.64 mg/dL
LAB-005450Sat Oct 31, 2026 05:00 AMcreatinine0.7 mg/dL
LAB-005458Sat Oct 31, 2026 05:00 AMsodium137.0 mmol/L
LAB-005466Sat Oct 31, 2026 05:00 AMhemoglobin12.6 g/dL
LAB-005475Sat Oct 31, 2026 05:00 AMwbc8.27 x10^3/uL
LAB-005476Sat Oct 31, 2026 05:00 AMplatelets302.0 x10^3/uL
LAB-005451Sun Nov 01, 2026 05:00 AMcreatinine0.71 mg/dL
LAB-005459Sun Nov 01, 2026 05:00 AMsodium137.0 mmol/L
LAB-005467Sun Nov 01, 2026 05:00 AMhemoglobin13.15 g/dL
LAB-005477Sun Nov 01, 2026 05:00 AMwbc8.89 x10^3/uL
LAB-005478Sun Nov 01, 2026 05:00 AMplatelets234.0 x10^3/uL
LAB-005452Mon Nov 02, 2026 05:00 AMcreatinine0.74 mg/dL
LAB-005460Mon Nov 02, 2026 05:00 AMsodium142.0 mmol/L
LAB-005468Mon Nov 02, 2026 05:00 AMhemoglobin12.56 g/dL
LAB-005479Mon Nov 02, 2026 05:00 AMwbc9.68 x10^3/uL
LAB-005480Mon Nov 02, 2026 05:00 AMplatelets230.0 x10^3/uL
LAB-005453Tue Nov 03, 2026 05:00 AMcreatinine0.7 mg/dL
LAB-005461Tue Nov 03, 2026 05:00 AMsodium136.0 mmol/L
LAB-005469Tue Nov 03, 2026 05:00 AMhemoglobin12.71 g/dL
LAB-005481Tue Nov 03, 2026 05:00 AMwbc6.4 x10^3/uL
LAB-005482Tue Nov 03, 2026 05:00 AMplatelets191.0 x10^3/uL
LAB-005454Wed Nov 04, 2026 05:00 AMcreatinine0.7 mg/dL
LAB-005462Wed Nov 04, 2026 05:00 AMsodium142.0 mmol/L
LAB-005470Wed Nov 04, 2026 05:00 AMhemoglobin13.15 g/dL
LAB-005483Wed Nov 04, 2026 05:00 AMwbc8.16 x10^3/uL
LAB-005484Wed Nov 04, 2026 05:00 AMplatelets264.0 x10^3/uL
LAB-005455Thu Nov 05, 2026 05:00 AMcreatinine0.74 mg/dL
LAB-005463Thu Nov 05, 2026 05:00 AMsodium141.0 mmol/L
LAB-005471Thu Nov 05, 2026 05:00 AMhemoglobin13.04 g/dL
LAB-005485Thu Nov 05, 2026 05:00 AMwbc8.74 x10^3/uL
LAB-005486Thu Nov 05, 2026 05:00 AMplatelets223.0 x10^3/uL
LAB-005456Fri Nov 06, 2026 05:00 AMcreatinine0.73 mg/dL
LAB-005464Fri Nov 06, 2026 05:00 AMsodium141.0 mmol/L
LAB-005472Fri Nov 06, 2026 05:00 AMhemoglobin12.91 g/dL
LAB-005487Fri Nov 06, 2026 05:00 AMwbc6.68 x10^3/uL
LAB-005488Fri Nov 06, 2026 05:00 AMplatelets242.0 x10^3/uL
Vitals (132)
Vitals
RowWhenKindValueDetail
VIT-015650Fri Oct 30, 2026 09:26 AMspo294.0room air
VIT-015651Fri Oct 30, 2026 09:26 AMrr17.0
VIT-015694Fri Oct 30, 2026 09:26 AMtemp_c37.3
VIT-015695Fri Oct 30, 2026 09:26 AMhr74.0
VIT-015696Fri Oct 30, 2026 09:26 AMmap77.0
VIT-015697Fri Oct 30, 2026 09:26 AMgcs15.0
VIT-015652Fri Oct 30, 2026 05:26 PMspo296.0room air
VIT-015653Fri Oct 30, 2026 05:26 PMrr18.0
VIT-015698Fri Oct 30, 2026 05:26 PMtemp_c37.2
VIT-015699Fri Oct 30, 2026 05:26 PMhr74.0
VIT-015700Fri Oct 30, 2026 05:26 PMmap84.0
VIT-015701Fri Oct 30, 2026 05:26 PMgcs15.0
VIT-015654Sat Oct 31, 2026 01:26 AMspo297.0room air
VIT-015655Sat Oct 31, 2026 01:26 AMrr20.0
VIT-015702Sat Oct 31, 2026 01:26 AMtemp_c37.4
VIT-015703Sat Oct 31, 2026 01:26 AMhr85.0
VIT-015704Sat Oct 31, 2026 01:26 AMmap82.0
VIT-015705Sat Oct 31, 2026 01:26 AMgcs15.0
VIT-015656Sat Oct 31, 2026 09:26 AMspo295.0room air
VIT-015657Sat Oct 31, 2026 09:26 AMrr19.0
VIT-015706Sat Oct 31, 2026 09:26 AMtemp_c36.9
VIT-015707Sat Oct 31, 2026 09:26 AMhr75.0
VIT-015708Sat Oct 31, 2026 09:26 AMmap78.0
VIT-015709Sat Oct 31, 2026 09:26 AMgcs15.0
VIT-015658Sat Oct 31, 2026 05:26 PMspo295.0room air
VIT-015659Sat Oct 31, 2026 05:26 PMrr17.0
VIT-015710Sat Oct 31, 2026 05:26 PMtemp_c37.4
VIT-015711Sat Oct 31, 2026 05:26 PMhr72.0
VIT-015712Sat Oct 31, 2026 05:26 PMmap82.0
VIT-015713Sat Oct 31, 2026 05:26 PMgcs15.0
VIT-015660Sun Nov 01, 2026 01:26 AMspo298.0room air
VIT-015661Sun Nov 01, 2026 01:26 AMrr19.0
VIT-015714Sun Nov 01, 2026 01:26 AMtemp_c37.1
VIT-015715Sun Nov 01, 2026 01:26 AMhr75.0
VIT-015716Sun Nov 01, 2026 01:26 AMmap84.0
VIT-015717Sun Nov 01, 2026 01:26 AMgcs15.0
VIT-015662Sun Nov 01, 2026 09:26 AMspo295.0room air
VIT-015663Sun Nov 01, 2026 09:26 AMrr16.0
VIT-015718Sun Nov 01, 2026 09:26 AMtemp_c36.8
VIT-015719Sun Nov 01, 2026 09:26 AMhr73.0
VIT-015720Sun Nov 01, 2026 09:26 AMmap81.0
VIT-015721Sun Nov 01, 2026 09:26 AMgcs15.0
VIT-015664Sun Nov 01, 2026 05:26 PMspo298.0room air
VIT-015665Sun Nov 01, 2026 05:26 PMrr18.0
VIT-015722Sun Nov 01, 2026 05:26 PMtemp_c37.0
VIT-015723Sun Nov 01, 2026 05:26 PMhr71.0
VIT-015724Sun Nov 01, 2026 05:26 PMmap89.0
VIT-015725Sun Nov 01, 2026 05:26 PMgcs15.0
VIT-015666Mon Nov 02, 2026 01:26 AMspo295.0room air
VIT-015667Mon Nov 02, 2026 01:26 AMrr14.0
VIT-015726Mon Nov 02, 2026 01:26 AMtemp_c37.2
VIT-015727Mon Nov 02, 2026 01:26 AMhr69.0
VIT-015728Mon Nov 02, 2026 01:26 AMmap81.0
VIT-015729Mon Nov 02, 2026 01:26 AMgcs15.0
VIT-015668Mon Nov 02, 2026 09:26 AMspo295.0room air
VIT-015669Mon Nov 02, 2026 09:26 AMrr19.0
VIT-015730Mon Nov 02, 2026 09:26 AMtemp_c36.6
VIT-015731Mon Nov 02, 2026 09:26 AMhr92.0
VIT-015732Mon Nov 02, 2026 09:26 AMmap80.0
VIT-015733Mon Nov 02, 2026 09:26 AMgcs15.0
VIT-015670Mon Nov 02, 2026 05:26 PMspo297.0room air
VIT-015671Mon Nov 02, 2026 05:26 PMrr20.0
VIT-015734Mon Nov 02, 2026 05:26 PMtemp_c36.9
VIT-015735Mon Nov 02, 2026 05:26 PMhr77.0
VIT-015736Mon Nov 02, 2026 05:26 PMmap80.0
VIT-015737Mon Nov 02, 2026 05:26 PMgcs15.0
VIT-015672Tue Nov 03, 2026 01:26 AMspo294.0room air
VIT-015673Tue Nov 03, 2026 01:26 AMrr16.0
VIT-015738Tue Nov 03, 2026 01:26 AMtemp_c37.1
VIT-015739Tue Nov 03, 2026 01:26 AMhr86.0
VIT-015740Tue Nov 03, 2026 01:26 AMmap82.0
VIT-015741Tue Nov 03, 2026 01:26 AMgcs15.0
VIT-015674Tue Nov 03, 2026 09:26 AMspo296.0room air
VIT-015675Tue Nov 03, 2026 09:26 AMrr20.0
VIT-015742Tue Nov 03, 2026 09:26 AMtemp_c37.4
VIT-015743Tue Nov 03, 2026 09:26 AMhr71.0
VIT-015744Tue Nov 03, 2026 09:26 AMmap81.0
VIT-015745Tue Nov 03, 2026 09:26 AMgcs15.0
VIT-015676Tue Nov 03, 2026 05:26 PMspo294.0room air
VIT-015677Tue Nov 03, 2026 05:26 PMrr14.0
VIT-015746Tue Nov 03, 2026 05:26 PMtemp_c36.7
VIT-015747Tue Nov 03, 2026 05:26 PMhr71.0
VIT-015748Tue Nov 03, 2026 05:26 PMmap83.0
VIT-015749Tue Nov 03, 2026 05:26 PMgcs15.0
VIT-015678Wed Nov 04, 2026 01:26 AMspo297.0room air
VIT-015679Wed Nov 04, 2026 01:26 AMrr20.0
VIT-015750Wed Nov 04, 2026 01:26 AMtemp_c37.3
VIT-015751Wed Nov 04, 2026 01:26 AMhr78.0
VIT-015752Wed Nov 04, 2026 01:26 AMmap79.0
VIT-015753Wed Nov 04, 2026 01:26 AMgcs15.0
VIT-015680Wed Nov 04, 2026 09:26 AMspo296.0room air
VIT-015681Wed Nov 04, 2026 09:26 AMrr19.0
VIT-015754Wed Nov 04, 2026 09:26 AMtemp_c36.5
VIT-015755Wed Nov 04, 2026 09:26 AMhr75.0
VIT-015756Wed Nov 04, 2026 09:26 AMmap78.0
VIT-015757Wed Nov 04, 2026 09:26 AMgcs15.0
VIT-015682Wed Nov 04, 2026 05:26 PMspo297.0room air
VIT-015683Wed Nov 04, 2026 05:26 PMrr14.0
VIT-015758Wed Nov 04, 2026 05:26 PMtemp_c37.6
VIT-015759Wed Nov 04, 2026 05:26 PMhr69.0
VIT-015760Wed Nov 04, 2026 05:26 PMmap86.0
VIT-015761Wed Nov 04, 2026 05:26 PMgcs15.0
VIT-015684Thu Nov 05, 2026 01:26 AMspo295.0room air
VIT-015685Thu Nov 05, 2026 01:26 AMrr14.0
VIT-015762Thu Nov 05, 2026 01:26 AMtemp_c36.8
VIT-015763Thu Nov 05, 2026 01:26 AMhr75.0
VIT-015764Thu Nov 05, 2026 01:26 AMmap74.0
VIT-015765Thu Nov 05, 2026 01:26 AMgcs15.0
VIT-015686Thu Nov 05, 2026 09:26 AMspo296.0room air
VIT-015687Thu Nov 05, 2026 09:26 AMrr19.0
VIT-015766Thu Nov 05, 2026 09:26 AMtemp_c37.5
VIT-015767Thu Nov 05, 2026 09:26 AMhr88.0
VIT-015768Thu Nov 05, 2026 09:26 AMmap84.0
VIT-015769Thu Nov 05, 2026 09:26 AMgcs15.0
VIT-015688Thu Nov 05, 2026 05:26 PMspo295.0room air
VIT-015689Thu Nov 05, 2026 05:26 PMrr15.0
VIT-015770Thu Nov 05, 2026 05:26 PMtemp_c37.3
VIT-015771Thu Nov 05, 2026 05:26 PMhr81.0
VIT-015772Thu Nov 05, 2026 05:26 PMmap92.0
VIT-015773Thu Nov 05, 2026 05:26 PMgcs15.0
VIT-015690Fri Nov 06, 2026 01:26 AMspo297.0room air
VIT-015691Fri Nov 06, 2026 01:26 AMrr16.0
VIT-015774Fri Nov 06, 2026 01:26 AMtemp_c36.8
VIT-015775Fri Nov 06, 2026 01:26 AMhr77.0
VIT-015776Fri Nov 06, 2026 01:26 AMmap78.0
VIT-015777Fri Nov 06, 2026 01:26 AMgcs15.0
VIT-015692Fri Nov 06, 2026 09:26 AMspo295.0room air
VIT-015693Fri Nov 06, 2026 09:26 AMrr19.0
VIT-015778Fri Nov 06, 2026 09:26 AMtemp_c37.4
VIT-015779Fri Nov 06, 2026 09:26 AMhr72.0
VIT-015780Fri Nov 06, 2026 09:26 AMmap88.0
VIT-015781Fri Nov 06, 2026 09:26 AMgcs15.0
Medications, orders, echo, history (4)

Notes

History and physical · DOC-000538 · Dr. Elena Nakashima (resident) · Fri Oct 30, 2026 12:06 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. Isaac Abernath History of present illness: 80-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: none significant. Review of systems otherwise negative. Exam: Lungs: clear to auscultation …
Source document DOC-000538: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Greta Nakashima   MRN: MRN13032350   Admitted: 2026-10-30 09:06
Service: Hospital Medicine   Attending: Dr. Isaac Abernath

History of present illness: 80-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: none significant.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Nutrition assessment · DOC-000537 · Vera Pemberton, RD (dietitian) · Sat Oct 31, 2026 11:06 AM

Cited facts from this note (5)
fat_loss
none · cited p. 1, line 7 · confidence 0.90
Show source for fat_loss
… MRN: MRN13032350 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: Greta Nakashima MRN: MRN13032350 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: Greta Nakashima MRN: MRN13032350 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-000537: Nutrition assessment (synthetic)
NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Greta Nakashima   MRN: MRN13032350

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-000539 · Dr. Elena Nakashima (resident) · Sun Nov 01, 2026 01:06 PM

Source document DOC-000539: Progress note (synthetic)
PROGRESS NOTE (Resident)
Patient: Greta Nakashima   MRN: MRN13032350   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.

Resident: Dr. Elena Nakashima   Attending cosign: completed

Discharge summary · DOC-000540 · Dr. Isaac Abernath (attending) · Fri Nov 06, 2026 10:56 AM

Source document DOC-000540: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Greta Nakashima   MRN: MRN13032350
Admitted 2026-10-30; discharged 2026-11-06.

Discharge diagnoses:
- community-acquired pneumonia

Disposition: home with follow-up.