ETHOS–P1 Clinical Interface

AMBULATORY VISIT NOTE Date: 04.12.2025 | Facility: NZOZ Centrum Medyczne CHIEF COMPLAINT: Progressive dyspnea on exertion × 2 weeks, new bilateral ankle edema, increased morning cough with sputum production. HISTORY OF PRESENT ILLNESS: 67-year-old male with known severe COPD (GOLD III), T2DM, HTN, and atrial fibrillation presenting with worsening respiratory symptoms. Patient reports increased breathlessness with activities previously tolerated (walking <100m), accompanied by new bilateral lower extremity swelling noted over past week. Morning cough has become more productive with whitish sputum. No fever, chest pain, or hemoptysis reported. RELEVANT HISTORY (ETHOS-summarized from P1): • 2 COPD exacerbations requiring hospitalization in past 12 months • Heart failure hospitalization June 2024 • Most recent FEV1: 42% predicted (declining from 48% in 2024) • Recent labs: HbA1c 7.8%, eGFR 58, BNP 245 pg/mL (elevated) CURRENT MEDICATIONS: Tiotropium 18mcg daily, Metformin 1000mg BID, Lisinopril 20mg daily, Apixaban 5mg BID ASSESSMENT: 1. COPD exacerbation, likely early/moderate 2. Possible HF decompensation component - new edema, elevated BNP 3. ETHOS 90-day hospitalization risk: 44% (high) PLAN: 1. Initiate oral corticosteroid burst (prednisone 40mg × 5 days) 2. Add furosemide 20mg daily for volume management, monitor weight daily 3. Sputum culture if purulent; consider antibiotics if bacterial etiology 4. Cardiology referral for HF optimization 5. Pulmonology follow-up in 2 weeks; sooner if worsening 6. Patient counseled on warning signs requiring ED evaluation — Draft generated by ETHOS from P1 data + pre-visit intake. Physician review required. —