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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-00172: Celeste Okafor

53M · MRN95315314 · Hospital Medicine · admitted Sun Oct 25, 2026 03:14 PM · discharged Sun Nov 01, 2026 01:16 PM · attending Dr. Odette Galloway · 164 cm, 62.8 kg

Documented diagnoses (current)

  • Principal: “urinary tract infection” · N39.0 Urinary tract infection, site not specified
  • “acute renal insufficiency” · N28.9 Disorder of kidney and ureter, unspecified (renal insufficiency)
  • “anemia” · D64.9 Anemia, unspecified

Illustrative grouping now: MS-DRG 690 Kidney and urinary tract infections without MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 690.

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 Specificity gap Documented “acute renal insufficiency” (N28.9); criteria support the more specific Acute kidney injury (KDIGO stage 2) (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=2.263, t.ratio_s1=1.5, creat_rise_48h=0.57, 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=2.263, t.ratio_s3=3.0, creat_peak=2.58, 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=2.263, 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=0.57, 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 No gap Supported as documented (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=M, hgb_nadir=10.65, 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=False, 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=301, t.chronic_days=90 true
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=73.0, egfr_late=76.9 76.9
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=73.0, t.g2=60, egfr_late=76.9 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=76.9, 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=73.0, egfr_late=76.9, t.g2=60 false
outcome: g1_g2 staging_egfr >= t.g2 staging_egfr=76.9, 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=53, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=23.3, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=23.3, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=23.3, t.c1=30 false
outcome: not_met bmi < t.c1 bmi=23.3, 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 met No gap Criteria support Sepsis (Sepsis-3); not documented (this rule does not prompt for an undocumented diagnosis).
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=84.0, 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=10.4, t.wbc_hi=12, wbc_min_48h=5.73, 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=198.0 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=0.62 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=2.58 2
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=1.14 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=2, sofa_renal_baseline=0 2
derived: sepsis3 infection_documented and sofa_delta >= t.sofa_delta infection_documented=True, sofa_delta=2, t.sofa_delta=2 true
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=True, 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=True, sepsis2=False false
outcome: sepsis3_only sepsis3 sepsis3=True true

Structured data

Labs (43)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-005882Sun Oct 26, 2025 09:15 AMcreatinine1.19 mg/dL
LAB-005883Sun Aug 23, 2026 10:05 AMcreatinine1.14 mg/dL
LAB-005884Sun Oct 25, 2026 04:14 PMcreatinine2.01 mg/dL
LAB-005892Sun Oct 25, 2026 04:14 PMsodium136.0 mmol/L
LAB-005900Sun Oct 25, 2026 04:14 PMhemoglobin11.01 g/dL
LAB-005908Sun Oct 25, 2026 04:14 PMwbc10.4 x10^3/uL
LAB-005909Sun Oct 25, 2026 04:14 PMplatelets242.0 x10^3/uL
LAB-005924Sun Oct 25, 2026 04:14 PMbilirubin0.62 mg/dL
LAB-005885Mon Oct 26, 2026 05:00 AMcreatinine2.58 mg/dL
LAB-005893Mon Oct 26, 2026 05:00 AMsodium139.0 mmol/L
LAB-005901Mon Oct 26, 2026 05:00 AMhemoglobin10.65 g/dL
LAB-005910Mon Oct 26, 2026 05:00 AMwbc5.97 x10^3/uL
LAB-005911Mon Oct 26, 2026 05:00 AMplatelets256.0 x10^3/uL
LAB-005886Tue Oct 27, 2026 05:00 AMcreatinine2.32 mg/dL
LAB-005894Tue Oct 27, 2026 05:00 AMsodium141.0 mmol/L
LAB-005902Tue Oct 27, 2026 05:00 AMhemoglobin10.98 g/dL
LAB-005912Tue Oct 27, 2026 05:00 AMwbc5.73 x10^3/uL
LAB-005913Tue Oct 27, 2026 05:00 AMplatelets198.0 x10^3/uL
LAB-005887Wed Oct 28, 2026 05:00 AMcreatinine1.93 mg/dL
LAB-005895Wed Oct 28, 2026 05:00 AMsodium136.0 mmol/L
LAB-005903Wed Oct 28, 2026 05:00 AMhemoglobin10.96 g/dL
LAB-005914Wed Oct 28, 2026 05:00 AMwbc5.67 x10^3/uL
LAB-005915Wed Oct 28, 2026 05:00 AMplatelets233.0 x10^3/uL
LAB-005888Thu Oct 29, 2026 05:00 AMcreatinine1.6 mg/dL
LAB-005896Thu Oct 29, 2026 05:00 AMsodium142.0 mmol/L
LAB-005904Thu Oct 29, 2026 05:00 AMhemoglobin10.68 g/dL
LAB-005916Thu Oct 29, 2026 05:00 AMwbc5.99 x10^3/uL
LAB-005917Thu Oct 29, 2026 05:00 AMplatelets175.0 x10^3/uL
LAB-005889Fri Oct 30, 2026 05:00 AMcreatinine1.42 mg/dL
LAB-005897Fri Oct 30, 2026 05:00 AMsodium142.0 mmol/L
LAB-005905Fri Oct 30, 2026 05:00 AMhemoglobin10.98 g/dL
LAB-005918Fri Oct 30, 2026 05:00 AMwbc7.27 x10^3/uL
LAB-005919Fri Oct 30, 2026 05:00 AMplatelets169.0 x10^3/uL
LAB-005890Sat Oct 31, 2026 05:00 AMcreatinine1.29 mg/dL
LAB-005898Sat Oct 31, 2026 05:00 AMsodium138.0 mmol/L
LAB-005906Sat Oct 31, 2026 05:00 AMhemoglobin11.02 g/dL
LAB-005920Sat Oct 31, 2026 05:00 AMwbc9.3 x10^3/uL
LAB-005921Sat Oct 31, 2026 05:00 AMplatelets258.0 x10^3/uL
LAB-005891Sun Nov 01, 2026 05:00 AMcreatinine1.24 mg/dL
LAB-005899Sun Nov 01, 2026 05:00 AMsodium138.0 mmol/L
LAB-005907Sun Nov 01, 2026 05:00 AMhemoglobin11.01 g/dL
LAB-005922Sun Nov 01, 2026 05:00 AMwbc6.03 x10^3/uL
LAB-005923Sun Nov 01, 2026 05:00 AMplatelets292.0 x10^3/uL
Vitals (126)
Vitals
RowWhenKindValueDetail
VIT-016936Sun Oct 25, 2026 03:34 PMspo294.0room air
VIT-016937Sun Oct 25, 2026 03:34 PMrr15.0
VIT-016978Sun Oct 25, 2026 03:34 PMtemp_c37.2
VIT-016979Sun Oct 25, 2026 03:34 PMhr78.0
VIT-016980Sun Oct 25, 2026 03:34 PMmap84.0
VIT-016981Sun Oct 25, 2026 03:34 PMgcs15.0
VIT-016938Sun Oct 25, 2026 11:34 PMspo296.0room air
VIT-016939Sun Oct 25, 2026 11:34 PMrr15.0
VIT-016982Sun Oct 25, 2026 11:34 PMtemp_c37.3
VIT-016983Sun Oct 25, 2026 11:34 PMhr69.0
VIT-016984Sun Oct 25, 2026 11:34 PMmap77.0
VIT-016985Sun Oct 25, 2026 11:34 PMgcs15.0
VIT-016940Mon Oct 26, 2026 07:34 AMspo298.0room air
VIT-016941Mon Oct 26, 2026 07:34 AMrr20.0
VIT-016986Mon Oct 26, 2026 07:34 AMtemp_c36.9
VIT-016987Mon Oct 26, 2026 07:34 AMhr83.0
VIT-016988Mon Oct 26, 2026 07:34 AMmap87.0
VIT-016989Mon Oct 26, 2026 07:34 AMgcs15.0
VIT-016942Mon Oct 26, 2026 03:34 PMspo295.0room air
VIT-016943Mon Oct 26, 2026 03:34 PMrr20.0
VIT-016990Mon Oct 26, 2026 03:34 PMtemp_c37.3
VIT-016991Mon Oct 26, 2026 03:34 PMhr84.0
VIT-016992Mon Oct 26, 2026 03:34 PMmap80.0
VIT-016993Mon Oct 26, 2026 03:34 PMgcs15.0
VIT-016944Mon Oct 26, 2026 11:34 PMspo298.0room air
VIT-016945Mon Oct 26, 2026 11:34 PMrr16.0
VIT-016994Mon Oct 26, 2026 11:34 PMtemp_c37.4
VIT-016995Mon Oct 26, 2026 11:34 PMhr72.0
VIT-016996Mon Oct 26, 2026 11:34 PMmap78.0
VIT-016997Mon Oct 26, 2026 11:34 PMgcs15.0
VIT-016946Tue Oct 27, 2026 07:34 AMspo296.0room air
VIT-016947Tue Oct 27, 2026 07:34 AMrr14.0
VIT-016998Tue Oct 27, 2026 07:34 AMtemp_c37.3
VIT-016999Tue Oct 27, 2026 07:34 AMhr71.0
VIT-017000Tue Oct 27, 2026 07:34 AMmap78.0
VIT-017001Tue Oct 27, 2026 07:34 AMgcs15.0
VIT-016948Tue Oct 27, 2026 03:34 PMspo298.0room air
VIT-016949Tue Oct 27, 2026 03:34 PMrr16.0
VIT-017002Tue Oct 27, 2026 03:34 PMtemp_c37.2
VIT-017003Tue Oct 27, 2026 03:34 PMhr75.0
VIT-017004Tue Oct 27, 2026 03:34 PMmap75.0
VIT-017005Tue Oct 27, 2026 03:34 PMgcs15.0
VIT-016950Tue Oct 27, 2026 11:34 PMspo295.0room air
VIT-016951Tue Oct 27, 2026 11:34 PMrr16.0
VIT-017006Tue Oct 27, 2026 11:34 PMtemp_c36.9
VIT-017007Tue Oct 27, 2026 11:34 PMhr72.0
VIT-017008Tue Oct 27, 2026 11:34 PMmap88.0
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VIT-016952Wed Oct 28, 2026 07:34 AMspo296.0room air
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VIT-017010Wed Oct 28, 2026 07:34 AMtemp_c37.2
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VIT-016956Wed Oct 28, 2026 11:34 PMspo295.0room air
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VIT-016958Thu Oct 29, 2026 07:34 AMspo297.0room air
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VIT-016966Fri Oct 30, 2026 03:34 PMspo297.0room air
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VIT-016968Fri Oct 30, 2026 11:34 PMspo299.0room air
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VIT-017045Fri Oct 30, 2026 11:34 PMgcs15.0
VIT-016970Sat Oct 31, 2026 07:34 AMspo295.0room air
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VIT-017049Sat Oct 31, 2026 07:34 AMgcs15.0
VIT-016972Sat Oct 31, 2026 03:34 PMspo296.0room air
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VIT-017056Sat Oct 31, 2026 11:34 PMmap90.0
VIT-017057Sat Oct 31, 2026 11:34 PMgcs15.0
VIT-016976Sun Nov 01, 2026 07:34 AMspo298.0room air
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VIT-017058Sun Nov 01, 2026 07:34 AMtemp_c37.2
VIT-017059Sun Nov 01, 2026 07:34 AMhr89.0
VIT-017060Sun Nov 01, 2026 07:34 AMmap86.0
VIT-017061Sun Nov 01, 2026 07:34 AMgcs15.0
Medications, orders, echo, history (4)

Notes

History and physical · DOC-000578 · Dr. Odette Galloway (attending) · Sun Oct 25, 2026 06:14 PM

Cited facts from this note (1)
infection_source
urinary tract infection · cited p. 1, line 5 · confidence 0.85
Show source for infection_source
… MRN95315314 Admitted: 2026-10-25 15:14 Service: Hospital Medicine Attending: Dr. Odette Galloway History of present illness: 53-year-old man admitted with urinary tract infection. Urinalysis with pyuria; treated for acute pyelonephritis with cefepime. Past medical history: none significant. Review of systems otherwise negative. Exam: Lu …
Source document DOC-000578: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Celeste Okafor   MRN: MRN95315314   Admitted: 2026-10-25 15:14
Service: Hospital Medicine   Attending: Dr. Odette Galloway

History of present illness: 53-year-old man admitted with urinary tract infection. Urinalysis with pyuria; treated for acute pyelonephritis with cefepime.
Past medical history: none significant.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Urinary tract infection: antibiotics.

Nutrition assessment · DOC-000577 · Vera Pemberton, RD (dietitian) · Mon Oct 26, 2026 07:14 PM

Cited facts from this note (5)
fat_loss
none · cited p. 1, line 7 · confidence 0.90
Show source for fat_loss
… MRN: MRN95315314 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: Celeste Okafor MRN: MRN95315314 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: Celeste Okafor MRN: MRN95315314 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-000577: Nutrition assessment (synthetic)
NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Celeste Okafor   MRN: MRN95315314

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-000579 · Dr. Odette Galloway (attending) · Tue Oct 27, 2026 07:14 PM

Source document DOC-000579: Progress note (synthetic)
PROGRESS NOTE (Attending)
Patient: Celeste Okafor   MRN: MRN95315314   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Urinary tract infection: continue current management.
2. Acute renal insufficiency: trend creatinine, avoid nephrotoxins.
3. Anemia: trend hemoglobin.

Attending: Dr. Odette Galloway

Discharge summary · DOC-000580 · Dr. Odette Galloway (attending) · Sun Nov 01, 2026 01:16 PM

Source document DOC-000580: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Celeste Okafor   MRN: MRN95315314
Admitted 2026-10-25; discharged 2026-11-01.

Discharge diagnoses:
- urinary tract infection
- acute renal insufficiency
- anemia

Disposition: home with follow-up.