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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-00174: Lena Lindqvist

75M · MRN43307079 · Hospital Medicine · admitted Tue Nov 03, 2026 07:24 PM · discharged Tue Nov 10, 2026 12:36 PM · attending Dr. Odette Galloway · resident Dr. Greta Kowalczyk · 162 cm, 59.5 kg

Documented diagnoses (current)

  • Principal: “upper GI bleed” · K92.2 Gastrointestinal hemorrhage, unspecified
  • “acute hypoxic respiratory failure” · J96.01 Acute respiratory failure with hypoxia
  • “acute blood loss anemia” · D62 Acute posthemorrhagic anemia
  • “hypertension” · I10 Essential (primary) hypertension

Illustrative grouping now: MS-DRG 377 GI hemorrhage with MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 378.

Queries and events

No queries yet.

All rules applied

Every rule's outcome for this encounter (clean results included)
RuleCriteriaFindingOutcome
Acute kidney injury Clinical judgement required Clinical judgement required Clinical judgement required: AKI criteria met only against a presumed baseline (no pre-admission creatinine on file).
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=1.787, t.ratio_s1=1.5, creat_rise_48h=0.02, 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=1.787, t.ratio_s3=3.0, creat_peak=1.68, 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=1.787, 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=True 1
derived: baseline_independent creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started creat_baseline_known=False, creat_rise_48h=0.02, t.rise_abs=0.3, rrt_started=False false
outcome: aki_staged stage >= 1 and baseline_independent stage=1, baseline_independent=False false
outcome: aki_presumed_baseline stage >= 1 stage=1 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=M, hgb_nadir=11.21, 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 Insufficient data No gap Insufficient data: the criteria could not be applied.
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=0, egfr_span_days=unknown, t.chronic_days=90 false
derived: staging_egfr max(egfr_early, egfr_late) egfr_early=unknown, egfr_late=unknown unknown
derived: both_below_60 egfr_early < t.g2 and egfr_late < t.g2 egfr_early=unknown, t.g2=60, egfr_late=unknown unknown
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=unknown, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15 unknown
outcome: duration_not_shown not chronic chronic=False true
Heart failure Clinical judgement required No gap Not documented; only one acute indicator; acuity needs clinical judgement.
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=True 1
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=1, 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=1 true
Hyponatraemia Criteria not met No gap Not documented and not supported.
Trace
Rule trace (rule hyponatremia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
StepExpressionInputs and thresholds readResult
derived: severity case(na_min < t.profound, 'profound', na_min < t.moderate, 'moderate', na_min < t.low, 'mild', 'none') na_min=136.0, t.profound=125, t.moderate=130, t.low=135 none
outcome: met na_min < t.low and na_low_count >= t.repeat and na_treated na_min=136.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False false
outcome: untreated na_min < t.low na_min=136.0, t.low=135 false
outcome: not_met na_min >= t.low na_min=136.0, t.low=135 true
Malnutrition Criteria met Specificity gap Criteria support Moderate (non-severe) protein-calorie malnutrition (acute illness context) (E44.0); no corresponding diagnosis is documented.
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=70.0, t.a_sev_intake_pct=50, intake_days=10.0, t.a_sev_intake_days=5 false
derived: a_mod_intake intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days intake_pct=70.0, t.a_mod_intake_pct=75, intake_days=10.0, t.a_mod_intake_days=7 true
derived: a_sev_wt (wt_loss_days <= 7 and wt_loss_pct > 2) or (wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5) wt_loss_days=30.0, wt_loss_pct=5.4 true
derived: a_mod_wt (wt_loss_days <= 7 and wt_loss_pct >= 1) or (wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5) wt_loss_days=30.0, wt_loss_pct=5.4 true
derived: c_sev_intake intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days intake_pct=70.0, t.c_intake_pct=75, intake_days=10.0, t.c_intake_days=30 false
derived: c_mod_intake intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days intake_pct=70.0, t.c_intake_pct=75, intake_days=10.0, t.c_intake_days=30 false
derived: c_sev_wt (wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5) or (wt_loss_days <= 183 and wt_loss_pct > 10) or (wt_loss_days <= 366 and wt_loss_pct > 20) wt_loss_days=30.0, wt_loss_pct=5.4 true
derived: c_mod_wt (wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5) or (wt_loss_days <= 183 and wt_loss_pct >= 10) or (wt_loss_days <= 366 and wt_loss_pct >= 20) wt_loss_days=30.0, wt_loss_pct=5.4 true
derived: n_assessed known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced) intake_pct=70.0, wt_loss_pct=5.4, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown 5
derived: n_severe case(nutr_context == 'acute', count(a_sev_intake, a_sev_wt, fat_loss >= 2, muscle_loss >= 2, fluid >= 2, grip_reduced), nutr_context == 'chronic', count(c_sev_intake, c_sev_wt, fat_loss >= 3, muscle_loss >= 3, fluid >= 3, grip_reduced), null) nutr_context=acute, a_sev_intake=False, a_sev_wt=True, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_sev_wt=True 1
derived: n_moderate case(nutr_context == 'acute', count(a_sev_intake or a_mod_intake, a_sev_wt or a_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), nutr_context == 'chronic', count(c_sev_intake or c_mod_intake, c_sev_wt or c_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), null) nutr_context=acute, a_sev_intake=False, a_mod_intake=True, a_sev_wt=True, a_mod_wt=True, fat_loss=1, muscle_loss=1, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_mod_intake=False, c_sev_wt=True, c_mod_wt=True 4
outcome: severe n_severe >= 2 n_severe=1 false
outcome: moderate n_moderate >= 2 n_moderate=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=75, t.adult=20 false
outcome: class3 bmi >= t.c3 bmi=22.7, t.c3=40 false
outcome: class2 bmi >= t.c2 bmi=22.7, t.c2=35 false
outcome: class1 bmi >= t.c1 bmi=22.7, t.c1=30 false
outcome: not_met bmi < t.c1 bmi=22.7, 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 Clinical validation gap Documented “acute hypoxic respiratory failure” (J96.01) but the criteria are not met: No hypoxaemia on room air (lowest SpO2 93%), oxygen no more than 2 L/min, no advanced support.
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=93.0, 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=93.0, 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=21.0, 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=2.0, 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=87.0, 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=8.63, t.wbc_hi=12, wbc_min_48h=5.72, 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=211.0 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=0.61 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=79.0 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=1.68 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=0.94 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 (41)
Labs (pre-admission rows are outpatient values)
RowWhenTestValue
LAB-005949Tue Nov 03, 2026 08:24 PMcreatinine1.68 mg/dL
LAB-005957Tue Nov 03, 2026 08:24 PMsodium140.0 mmol/L
LAB-005965Tue Nov 03, 2026 08:24 PMhemoglobin11.61 g/dL
LAB-005973Tue Nov 03, 2026 08:24 PMwbc6.37 x10^3/uL
LAB-005974Tue Nov 03, 2026 08:24 PMplatelets211.0 x10^3/uL
LAB-005989Tue Nov 03, 2026 08:24 PMbilirubin0.61 mg/dL
LAB-005950Wed Nov 04, 2026 05:00 AMcreatinine1.39 mg/dL
LAB-005958Wed Nov 04, 2026 05:00 AMsodium139.0 mmol/L
LAB-005966Wed Nov 04, 2026 05:00 AMhemoglobin11.21 g/dL
LAB-005975Wed Nov 04, 2026 05:00 AMwbc5.72 x10^3/uL
LAB-005976Wed Nov 04, 2026 05:00 AMplatelets236.0 x10^3/uL
LAB-005951Thu Nov 05, 2026 05:00 AMcreatinine1.17 mg/dL
LAB-005959Thu Nov 05, 2026 05:00 AMsodium140.0 mmol/L
LAB-005967Thu Nov 05, 2026 05:00 AMhemoglobin11.61 g/dL
LAB-005977Thu Nov 05, 2026 05:00 AMwbc8.63 x10^3/uL
LAB-005978Thu Nov 05, 2026 05:00 AMplatelets258.0 x10^3/uL
LAB-005952Fri Nov 06, 2026 05:00 AMcreatinine1.04 mg/dL
LAB-005960Fri Nov 06, 2026 05:00 AMsodium141.0 mmol/L
LAB-005968Fri Nov 06, 2026 05:00 AMhemoglobin11.21 g/dL
LAB-005979Fri Nov 06, 2026 05:00 AMwbc9.14 x10^3/uL
LAB-005980Fri Nov 06, 2026 05:00 AMplatelets308.0 x10^3/uL
LAB-005953Sat Nov 07, 2026 05:00 AMcreatinine0.96 mg/dL
LAB-005961Sat Nov 07, 2026 05:00 AMsodium137.0 mmol/L
LAB-005969Sat Nov 07, 2026 05:00 AMhemoglobin11.61 g/dL
LAB-005981Sat Nov 07, 2026 05:00 AMwbc5.91 x10^3/uL
LAB-005982Sat Nov 07, 2026 05:00 AMplatelets191.0 x10^3/uL
LAB-005954Sun Nov 08, 2026 05:00 AMcreatinine0.94 mg/dL
LAB-005962Sun Nov 08, 2026 05:00 AMsodium138.0 mmol/L
LAB-005970Sun Nov 08, 2026 05:00 AMhemoglobin11.21 g/dL
LAB-005983Sun Nov 08, 2026 05:00 AMwbc6.12 x10^3/uL
LAB-005984Sun Nov 08, 2026 05:00 AMplatelets190.0 x10^3/uL
LAB-005955Mon Nov 09, 2026 05:00 AMcreatinine0.96 mg/dL
LAB-005963Mon Nov 09, 2026 05:00 AMsodium139.0 mmol/L
LAB-005971Mon Nov 09, 2026 05:00 AMhemoglobin11.61 g/dL
LAB-005985Mon Nov 09, 2026 05:00 AMwbc7.45 x10^3/uL
LAB-005986Mon Nov 09, 2026 05:00 AMplatelets244.0 x10^3/uL
LAB-005956Tue Nov 10, 2026 05:00 AMcreatinine0.95 mg/dL
LAB-005964Tue Nov 10, 2026 05:00 AMsodium136.0 mmol/L
LAB-005972Tue Nov 10, 2026 05:00 AMhemoglobin11.21 g/dL
LAB-005987Tue Nov 10, 2026 05:00 AMwbc5.69 x10^3/uL
LAB-005988Tue Nov 10, 2026 05:00 AMplatelets194.0 x10^3/uL
Vitals (128)
Vitals
RowWhenKindValueDetail
VIT-017125Tue Nov 03, 2026 07:44 PMspo294.0room air
VIT-017126Tue Nov 03, 2026 07:44 PMrr16.0
VIT-017169Tue Nov 03, 2026 07:44 PMtemp_c37.4
VIT-017170Tue Nov 03, 2026 07:44 PMhr73.0
VIT-017171Tue Nov 03, 2026 07:44 PMmap87.0
VIT-017172Tue Nov 03, 2026 07:44 PMgcs15.0
VIT-017127Wed Nov 04, 2026 03:44 AMspo294.0room air
VIT-017128Wed Nov 04, 2026 03:44 AMrr17.0
VIT-017173Wed Nov 04, 2026 03:44 AMtemp_c36.9
VIT-017174Wed Nov 04, 2026 03:44 AMhr86.0
VIT-017175Wed Nov 04, 2026 03:44 AMmap79.0
VIT-017176Wed Nov 04, 2026 03:44 AMgcs15.0
VIT-017129Wed Nov 04, 2026 03:49 AMo2_lpm2.0nasal cannula
VIT-017130Wed Nov 04, 2026 11:44 AMspo294.0room air
VIT-017131Wed Nov 04, 2026 11:44 AMrr16.0
VIT-017177Wed Nov 04, 2026 11:44 AMtemp_c36.9
VIT-017178Wed Nov 04, 2026 11:44 AMhr87.0
VIT-017179Wed Nov 04, 2026 11:44 AMmap87.0
VIT-017180Wed Nov 04, 2026 11:44 AMgcs15.0
VIT-017132Wed Nov 04, 2026 11:49 AMo2_lpm2.0nasal cannula
VIT-017133Wed Nov 04, 2026 07:44 PMspo294.0room air
VIT-017134Wed Nov 04, 2026 07:44 PMrr18.0
VIT-017181Wed Nov 04, 2026 07:44 PMtemp_c37.4
VIT-017182Wed Nov 04, 2026 07:44 PMhr80.0
VIT-017183Wed Nov 04, 2026 07:44 PMmap80.0
VIT-017184Wed Nov 04, 2026 07:44 PMgcs15.0
VIT-017135Thu Nov 05, 2026 03:44 AMspo293.0room air
VIT-017136Thu Nov 05, 2026 03:44 AMrr20.0
VIT-017185Thu Nov 05, 2026 03:44 AMtemp_c37.2
VIT-017186Thu Nov 05, 2026 03:44 AMhr72.0
VIT-017187Thu Nov 05, 2026 03:44 AMmap89.0
VIT-017188Thu Nov 05, 2026 03:44 AMgcs15.0
VIT-017137Thu Nov 05, 2026 11:44 AMspo297.0room air
VIT-017138Thu Nov 05, 2026 11:44 AMrr16.0
VIT-017189Thu Nov 05, 2026 11:44 AMtemp_c37.1
VIT-017190Thu Nov 05, 2026 11:44 AMhr72.0
VIT-017191Thu Nov 05, 2026 11:44 AMmap86.0
VIT-017192Thu Nov 05, 2026 11:44 AMgcs15.0
VIT-017139Thu Nov 05, 2026 07:44 PMspo295.0room air
VIT-017140Thu Nov 05, 2026 07:44 PMrr16.0
VIT-017193Thu Nov 05, 2026 07:44 PMtemp_c37.2
VIT-017194Thu Nov 05, 2026 07:44 PMhr75.0
VIT-017195Thu Nov 05, 2026 07:44 PMmap92.0
VIT-017196Thu Nov 05, 2026 07:44 PMgcs15.0
VIT-017141Fri Nov 06, 2026 03:44 AMspo295.0room air
VIT-017142Fri Nov 06, 2026 03:44 AMrr18.0
VIT-017197Fri Nov 06, 2026 03:44 AMtemp_c36.7
VIT-017198Fri Nov 06, 2026 03:44 AMhr88.0
VIT-017199Fri Nov 06, 2026 03:44 AMmap92.0
VIT-017200Fri Nov 06, 2026 03:44 AMgcs15.0
VIT-017143Fri Nov 06, 2026 11:44 AMspo293.0room air
VIT-017144Fri Nov 06, 2026 11:44 AMrr21.0
VIT-017201Fri Nov 06, 2026 11:44 AMtemp_c36.6
VIT-017202Fri Nov 06, 2026 11:44 AMhr89.0
VIT-017203Fri Nov 06, 2026 11:44 AMmap77.0
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Medications, orders, echo, history (0)

Notes

History and physical · DOC-000584 · Dr. Greta Kowalczyk (resident) · Tue Nov 03, 2026 10:24 PM

Cited facts from this note (1)
bleeding_source
hematemesis · cited p. 1, line 5 · confidence 0.85
Show source for bleeding_source
… vice: Hospital Medicine Attending: Dr. Odette Galloway History of present illness: 75-year-old man admitted with upper GI bleed. Presented after two days of hematemesis; GI consulted for endoscopy. Past medical history: hypertension. Review of systems otherwise negative. Exam: Lungs: clear to auscultation bilaterally. Assessme …
Source document DOC-000584: History and physical (synthetic)
HISTORY AND PHYSICAL
Patient: Lena Lindqvist   MRN: MRN43307079   Admitted: 2026-11-03 19:24
Service: Hospital Medicine   Attending: Dr. Odette Galloway

History of present illness: 75-year-old man admitted with upper GI bleed. Presented after two days of hematemesis; GI consulted for endoscopy.
Past medical history: hypertension.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Upper GI bleed: PPI, GI following.

Nutrition assessment · DOC-000583 · Vera Pemberton, RD (dietitian) · Thu Nov 05, 2026 01:24 AM

Cited facts from this note (8)
fat_loss
mild · cited p. 1, line 7 · confidence 0.90
Show source for fat_loss
… ontext: acute illness Intake: estimated energy intake 70% of needs for 10 days. Weight history: 5.4% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
fluid_accumulation
none · cited p. 1, line 7 · confidence 0.90
Show source for fluid_accumulation
… e 70% of needs for 10 days. Weight history: 5.4% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
intake_days
10 · cited p. 1, line 5 · confidence 0.95
Show source for intake_days
NUTRITION ASSESSMENT (Registered Dietitian) Patient: Lena Lindqvist MRN: MRN43307079 Context: acute illness Intake: estimated energy intake 70% of needs for 10 days. Weight history: 5.4% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Rec …
intake_pct
70 · cited p. 1, line 5 · confidence 0.95
Show source for intake_pct
NUTRITION ASSESSMENT (Registered Dietitian) Patient: Lena Lindqvist MRN: MRN43307079 Context: acute illness Intake: estimated energy intake 70% of needs for 10 days. Weight history: 5.4% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Rec …
muscle_loss
mild · cited p. 1, line 7 · confidence 0.90
Show source for muscle_loss
… stimated energy intake 70% of needs for 10 days. Weight history: 5.4% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; calorie counts; weekly weights.
nutrition_context
acute · cited p. 1, line 4 · confidence 0.95
Show source for nutrition_context
NUTRITION ASSESSMENT (Registered Dietitian) Patient: Lena Lindqvist MRN: MRN43307079 Context: acute illness Intake: estimated energy intake 70% of needs for 10 days. Weight history: 5.4% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutan …
weight_loss_days
30 · cited p. 1, line 6 · confidence 0.95
Show source for weight_loss_days
… istered Dietitian) Patient: Lena Lindqvist MRN: MRN43307079 Context: acute illness Intake: estimated energy intake 70% of needs for 10 days. Weight history: 5.4% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; cal …
weight_loss_pct
5.4 · cited p. 1, line 6 · confidence 0.95
Show source for weight_loss_pct
… istered Dietitian) Patient: Lena Lindqvist MRN: MRN43307079 Context: acute illness Intake: estimated energy intake 70% of needs for 10 days. Weight history: 5.4% weight loss over 30 days. Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation. Recommendations: high-protein oral supplement; cal …
Source document DOC-000583: Nutrition assessment (synthetic)
NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Lena Lindqvist   MRN: MRN43307079

Context: acute illness
Intake: estimated energy intake 70% of needs for 10 days.
Weight history: 5.4% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Recommendations: high-protein oral supplement; calorie counts; weekly weights.

Progress note · DOC-000585 · Dr. Greta Kowalczyk (resident) · Thu Nov 05, 2026 09:24 PM

Source document DOC-000585: Progress note (synthetic)
PROGRESS NOTE (Resident)
Patient: Lena Lindqvist   MRN: MRN43307079   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. Acute hypoxic respiratory failure: supplemental oxygen, wean as tolerated.
3. Acute blood loss anemia: trend hemoglobin, transfuse if needed.

Resident: Dr. Greta Kowalczyk   Attending cosign: completed

Discharge summary · DOC-000586 · Dr. Odette Galloway (attending) · Tue Nov 10, 2026 12:36 PM

Source document DOC-000586: Discharge summary (synthetic)
DISCHARGE SUMMARY
Patient: Lena Lindqvist   MRN: MRN43307079
Admitted 2026-11-03; discharged 2026-11-10.

Discharge diagnoses:
- upper GI bleed
- acute hypoxic respiratory failure
- acute blood loss anemia
- hypertension

Disposition: home with follow-up.