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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-00168: Zara Stavros

73F · MRN29850384 · Hospital Medicine · admitted Wed Oct 28, 2026 09:07 AM · discharged Thu Nov 05, 2026 02:32 PM · attending Dr. Cyrus Ellingham · resident Dr. Camila Oyelaran · 167 cm, 70.9 kg

Documented diagnoses (current)

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

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=1.043, 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=1.043, t.ratio_s3=3.0, creat_peak=0.73, 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=1.043, 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=13.61, 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=0.5, 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=0.5, t.drop_min=1.0, prbc_units=0 false
outcome: not_anaemic present(hgb_nadir) and not anaemic hgb_nadir=13.61, 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=284, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=91.3, egfr_late=91.3 91.3
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=91.3, t.g2=60, egfr_late=91.3 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=91.3, 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=91.3, egfr_late=91.3, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=91.3, 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 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=73, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=25.4, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=25.4, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=25.4, t.c1=30 false
outcome: not_met bmi < t.c1 bmi=25.4, 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=36.7, 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=8.31, t.wbc_hi=12, wbc_min_48h=6.82, 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=244.0 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=0.63 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=0.72 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=0.7 0
derived: sofa_delta sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline sofa_resp=0, sofa_coag=0, sofa_liver=0, sofa_cardio=0, sofa_cns=0, sofa_renal=0, sofa_renal_baseline=0 0
derived: sepsis3 infection_documented and sofa_delta >= t.sofa_delta infection_documented=True, sofa_delta=0, t.sofa_delta=2 false
derived: sepsis2 infection_documented and sirs_count >= t.sirs_min infection_documented=True, sirs_count=0, t.sirs_min=2 false
derived: shock sepsis3 and norepi_max_48h > 0 and coalesce(lactate_max_48h > t.lactate, false) sepsis3=False, norepi_max_48h=0.0, lactate_max_48h=unknown, t.lactate=2 false
outcome: no_infection not infection_documented infection_documented=True false
outcome: septic_shock shock shock=False false
outcome: both sepsis3 and sepsis2 sepsis3=False, sepsis2=False false
outcome: sepsis3_only sepsis3 sepsis3=False false
outcome: definitions_disagree sepsis2 sepsis2=False false
outcome: neither true — true

Structured data

Labs (48)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-005733Thu Dec 04, 2025 09:15 AMcreatinine0.7 mg/dL
LAB-005734Tue Sep 15, 2026 10:05 AMcreatinine0.7 mg/dL
LAB-005735Wed Oct 28, 2026 10:07 AMcreatinine0.69 mg/dL
LAB-005744Wed Oct 28, 2026 10:07 AMsodium136.0 mmol/L
LAB-005753Wed Oct 28, 2026 10:07 AMhemoglobin14.07 g/dL
LAB-005762Wed Oct 28, 2026 10:07 AMwbc8.31 x10^3/uL
LAB-005763Wed Oct 28, 2026 10:07 AMplatelets255.0 x10^3/uL
LAB-005780Wed Oct 28, 2026 10:07 AMbilirubin0.63 mg/dL
LAB-005736Thu Oct 29, 2026 05:00 AMcreatinine0.7 mg/dL
LAB-005745Thu Oct 29, 2026 05:00 AMsodium140.0 mmol/L
LAB-005754Thu Oct 29, 2026 05:00 AMhemoglobin14.09 g/dL
LAB-005764Thu Oct 29, 2026 05:00 AMwbc7.81 x10^3/uL
LAB-005765Thu Oct 29, 2026 05:00 AMplatelets244.0 x10^3/uL
LAB-005737Fri Oct 30, 2026 05:00 AMcreatinine0.72 mg/dL
LAB-005746Fri Oct 30, 2026 05:00 AMsodium142.0 mmol/L
LAB-005755Fri Oct 30, 2026 05:00 AMhemoglobin13.72 g/dL
LAB-005766Fri Oct 30, 2026 05:00 AMwbc6.82 x10^3/uL
LAB-005767Fri Oct 30, 2026 05:00 AMplatelets284.0 x10^3/uL
LAB-005738Sat Oct 31, 2026 05:00 AMcreatinine0.7 mg/dL
LAB-005747Sat Oct 31, 2026 05:00 AMsodium140.0 mmol/L
LAB-005756Sat Oct 31, 2026 05:00 AMhemoglobin13.61 g/dL
LAB-005768Sat Oct 31, 2026 05:00 AMwbc5.94 x10^3/uL
LAB-005769Sat Oct 31, 2026 05:00 AMplatelets202.0 x10^3/uL
LAB-005739Sun Nov 01, 2026 05:00 AMcreatinine0.7 mg/dL
LAB-005748Sun Nov 01, 2026 05:00 AMsodium138.0 mmol/L
LAB-005757Sun Nov 01, 2026 05:00 AMhemoglobin13.74 g/dL
LAB-005770Sun Nov 01, 2026 05:00 AMwbc6.93 x10^3/uL
LAB-005771Sun Nov 01, 2026 05:00 AMplatelets189.0 x10^3/uL
LAB-005740Mon Nov 02, 2026 05:00 AMcreatinine0.71 mg/dL
LAB-005749Mon Nov 02, 2026 05:00 AMsodium141.0 mmol/L
LAB-005758Mon Nov 02, 2026 05:00 AMhemoglobin14.04 g/dL
LAB-005772Mon Nov 02, 2026 05:00 AMwbc6.82 x10^3/uL
LAB-005773Mon Nov 02, 2026 05:00 AMplatelets198.0 x10^3/uL
LAB-005741Tue Nov 03, 2026 05:00 AMcreatinine0.73 mg/dL
LAB-005750Tue Nov 03, 2026 05:00 AMsodium139.0 mmol/L
LAB-005759Tue Nov 03, 2026 05:00 AMhemoglobin13.82 g/dL
LAB-005774Tue Nov 03, 2026 05:00 AMwbc7.34 x10^3/uL
LAB-005775Tue Nov 03, 2026 05:00 AMplatelets226.0 x10^3/uL
LAB-005742Wed Nov 04, 2026 05:00 AMcreatinine0.69 mg/dL
LAB-005751Wed Nov 04, 2026 05:00 AMsodium139.0 mmol/L
LAB-005760Wed Nov 04, 2026 05:00 AMhemoglobin13.64 g/dL
LAB-005776Wed Nov 04, 2026 05:00 AMwbc10.85 x10^3/uL
LAB-005777Wed Nov 04, 2026 05:00 AMplatelets204.0 x10^3/uL
LAB-005743Thu Nov 05, 2026 05:00 AMcreatinine0.73 mg/dL
LAB-005752Thu Nov 05, 2026 05:00 AMsodium142.0 mmol/L
LAB-005761Thu Nov 05, 2026 05:00 AMhemoglobin13.7 g/dL
LAB-005778Thu Nov 05, 2026 05:00 AMwbc8.75 x10^3/uL
LAB-005779Thu Nov 05, 2026 05:00 AMplatelets232.0 x10^3/uL
Vitals (150)
Vitals
RowWhenKindValueDetail
VIT-016504Wed Oct 28, 2026 09:27 AMspo299.0room air
VIT-016505Wed Oct 28, 2026 09:27 AMrr17.0
VIT-016554Wed Oct 28, 2026 09:27 AMtemp_c37.6
VIT-016555Wed Oct 28, 2026 09:27 AMhr75.0
VIT-016556Wed Oct 28, 2026 09:27 AMmap81.0
VIT-016557Wed Oct 28, 2026 09:27 AMgcs15.0
VIT-016506Wed Oct 28, 2026 05:27 PMspo299.0room air
VIT-016507Wed Oct 28, 2026 05:27 PMrr17.0
VIT-016558Wed Oct 28, 2026 05:27 PMtemp_c36.7
VIT-016559Wed Oct 28, 2026 05:27 PMhr79.0
VIT-016560Wed Oct 28, 2026 05:27 PMmap81.0
VIT-016561Wed Oct 28, 2026 05:27 PMgcs15.0
VIT-016508Thu Oct 29, 2026 01:27 AMspo294.0room air
VIT-016509Thu Oct 29, 2026 01:27 AMrr16.0
VIT-016562Thu Oct 29, 2026 01:27 AMtemp_c36.7
VIT-016563Thu Oct 29, 2026 01:27 AMhr84.0
VIT-016564Thu Oct 29, 2026 01:27 AMmap77.0
VIT-016565Thu Oct 29, 2026 01:27 AMgcs15.0
VIT-016510Thu Oct 29, 2026 09:27 AMspo297.0room air
VIT-016511Thu Oct 29, 2026 09:27 AMrr18.0
VIT-016566Thu Oct 29, 2026 09:27 AMtemp_c37.3
VIT-016567Thu Oct 29, 2026 09:27 AMhr86.0
VIT-016568Thu Oct 29, 2026 09:27 AMmap89.0
VIT-016569Thu Oct 29, 2026 09:27 AMgcs15.0
VIT-016512Thu Oct 29, 2026 05:27 PMspo298.0room air
VIT-016513Thu Oct 29, 2026 05:27 PMrr20.0
VIT-016570Thu Oct 29, 2026 05:27 PMtemp_c36.8
VIT-016571Thu Oct 29, 2026 05:27 PMhr68.0
VIT-016572Thu Oct 29, 2026 05:27 PMmap90.0
VIT-016573Thu Oct 29, 2026 05:27 PMgcs15.0
VIT-016514Fri Oct 30, 2026 01:27 AMspo299.0room air
VIT-016515Fri Oct 30, 2026 01:27 AMrr16.0
VIT-016574Fri Oct 30, 2026 01:27 AMtemp_c37.4
VIT-016575Fri Oct 30, 2026 01:27 AMhr88.0
VIT-016576Fri Oct 30, 2026 01:27 AMmap79.0
VIT-016577Fri Oct 30, 2026 01:27 AMgcs15.0
VIT-016516Fri Oct 30, 2026 09:27 AMspo294.0room air
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VIT-016597Sat Oct 31, 2026 05:27 PMgcs15.0
VIT-016526Sun Nov 01, 2026 01:27 AMspo295.0room air
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VIT-016645Wed Nov 04, 2026 05:27 PMgcs15.0
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VIT-016648Thu Nov 05, 2026 01:27 AMmap83.0
VIT-016649Thu Nov 05, 2026 01:27 AMgcs15.0
VIT-016552Thu Nov 05, 2026 09:27 AMspo294.0room air
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VIT-016650Thu Nov 05, 2026 09:27 AMtemp_c37.0
VIT-016651Thu Nov 05, 2026 09:27 AMhr85.0
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VIT-016653Thu Nov 05, 2026 09:27 AMgcs15.0
Medications, orders, echo, history (4)

Notes

History and physical · DOC-000565 · Dr. Camila Oyelaran (resident) · Wed Oct 28, 2026 12:07 PM

Cited facts from this note (1)
infection_source
right lower lobe pneumonia · cited p. 1, line 5 · confidence 0.85
Show source for infection_source
… Hospital Medicine Attending: Dr. Cyrus Ellingham History of present illness: 73-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows right lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: hyperlipidemia, GERD, hypertension. Review of systems otherwise negative. Exam: Lungs: cle …
Source document DOC-000565: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Zara Stavros   MRN: MRN29850384   Admitted: 2026-10-28 09:07
Service: Hospital Medicine   Attending: Dr. Cyrus Ellingham

History of present illness: 73-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows right lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: hyperlipidemia, GERD, hypertension.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Progress note · DOC-000566 · Dr. Camila Oyelaran (resident) · Fri Oct 30, 2026 12:07 PM

Source document DOC-000566: Progress note (synthetic)
PROGRESS NOTE (Resident)
Patient: Zara Stavros   MRN: MRN29850384   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. Camila Oyelaran   Attending cosign: completed

Discharge summary · DOC-000567 · Dr. Cyrus Ellingham (attending) · Thu Nov 05, 2026 02:32 PM

Source document DOC-000567: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Zara Stavros   MRN: MRN29850384
Admitted 2026-10-28; discharged 2026-11-05.

Discharge diagnoses:
- community-acquired pneumonia
- hyperlipidemia
- GERD
- hypertension

Disposition: home with follow-up.