VALVEPATH SYNTHETIC EMR EXPORT
FOR SOFTWARE TESTING ONLY — ENTIRELY FICTIONAL — NO REAL PATIENT DATA

CASE ID: VP-SYN-001
Record type: Synthetic longitudinal EMR summary for TAVR workflow testing
Encounter date: 2026-09-08
Patient pseudonym: Martin Vale (fictional)
Medical record number: SYNTHETIC-0001
Date of birth: 1954-04-18
Age: 72 years
Sex at birth: Male
Height: 175 cm
Weight: 82 kg
BMI: 26.8 kg/m2
Body surface area: 2.00 m2 (Mosteller)

STRUCTURAL HEART REFERRAL
Primary problem: Symptomatic calcific aortic stenosis under evaluation for TAVR.
Symptoms: Progressive exertional dyspnea, fatigue, and reduced exercise tolerance for 8 months.
NYHA functional class: III.
Angina: Denied.
Syncope or presyncope: Denied.
Heart-failure admission in past 12 months: One synthetic admission, 5 months ago.
KCCQ-12 overall summary score: 42 of 100.
Shared decision-making status: Initial heart-team discussion completed; final treatment decision pending.

PAST MEDICAL HISTORY
- Hypertension.
- Dyslipidemia.
- Type 2 diabetes mellitus, treated without insulin.
- Chronic kidney disease, stage 2.
- Pulmonary hypertension noted on echocardiography.
- No known chronic lung disease; no home oxygen.
- No prior myocardial infarction.
- No prior stroke or transient ischemic attack.
- No known peripheral arterial disease.
- No active malignancy, cirrhosis, chronic liver disease, or infection.

PRIOR CARDIAC PROCEDURES
- Bioprosthetic mitral valve replacement in 2019 for degenerative mitral regurgitation.
- No prior CABG, LIMA graft, SAVR, TAVR, pacemaker, ICD, or coronary stent.

CURRENT MEDICATIONS
- Aspirin 81 mg daily.
- Atorvastatin 40 mg daily.
- Losartan 50 mg daily.
- Metformin 500 mg twice daily.
- Furosemide 20 mg daily.
- No oral anticoagulant reported.

ALLERGIES
- No known drug allergies.

VITAL SIGNS
- Blood pressure: 132/76 mmHg.
- Heart rate: 72 beats/min.
- Respiratory rate: 16 breaths/min.
- Oxygen saturation: 97% on room air.
- Temperature: 36.7 C.

RECENT LABORATORY RESULTS
- Hemoglobin: 11.8 g/dL.
- Hematocrit: 35.6%.
- Platelets: 214 x10^3/uL.
- White blood cells: 6.8 x10^3/uL.
- Creatinine: 1.12 mg/dL.
- Estimated GFR: 70 mL/min/1.73 m2.
- Blood urea nitrogen: 24 mg/dL.
- Sodium: 139 mmol/L.
- Potassium: 4.3 mmol/L.
- Serum albumin: 3.3 g/dL.
- Total bilirubin: 0.7 mg/dL.
- INR: 1.0.
- Hemoglobin A1c: 6.8%.

FRAILTY AND FUNCTIONAL ASSESSMENT
- Five chair rises: 17.2 seconds; completed without using arms.
- Mini-Mental State Examination (MMSE): 27 of 30.
- Five-meter walk: 6.7 seconds on the first trial and 6.6 seconds on the second trial.
- Katz basic activities of daily living: 6 of 6; independent.
- Lawton instrumental activities of daily living: 6 of 8; needs help with shopping and transportation.
- Clinical Frailty Scale: 4 of 9, assigned by the evaluating clinician.
- Dominant-hand grip strength: 24 kg.
- Unintentional weight loss: 3 kg over 6 months.
- Falls in the past year: One, without injury.
- Mobility aid: None indoors; cane for long outdoor distances.
- Living situation: Lives with spouse; spouse available for post-procedure support.

RESPIRATORY AND NEUROLOGIC STATUS
- No home oxygen or chronic steroid therapy.
- FEV1: 78% predicted on a synthetic screening test.
- No focal neurologic deficit or known dementia.

CORONARY AND RHYTHM HISTORY
- No known atrial fibrillation, flutter, high-grade AV block, RBBB, or LBBB.
- Coronary angiography: No obstructive epicardial coronary disease reported in the synthetic note.

SURGICAL-RISK RESULTS IMPORTED FROM SYNTHETIC HEART-TEAM NOTE
- STS predicted risk of mortality for isolated surgical AVR: 4.2%.
  Calculator version, procedure configuration, and timestamp were not supplied.
- EuroSCORE II: 3.1%.
  Calculator version and timestamp were not supplied.

IMPORTANT: These are fictional externally reported values. ValvePath must extract them as
imported scores and must not represent that it independently recalculated or validated them.

PRE-PROCEDURE READINESS
- Dental clearance: Pending.
- Infection screen: No active infection reported.
- Blood type and screen: Not yet completed.
- Contrast-allergy history: None reported.
- Code status: Full code.
- Health-care proxy: Spouse.

SOURCE DOCUMENT STATUS
- TAVR CT planning report: Available separately as Test_1_Native.pdf.
- Transthoracic echocardiography report: Available separately as Echo_test_1.docx.
- Baseline ECG tracing: Available separately as ecg_test_1.png.
- Prior mitral operative report: Not supplied; history is synthetic EMR text only.

PROCEDURAL PLANNING STATUS
- Access route: Not selected.
- THV manufacturer, family, and size: Not selected.
- Intended implant depth: Not selected.
- Balloon filling volume: Not selected.
- Coronary protection strategy: Not selected.
- Cerebral embolic protection strategy: Not selected.
- Planned contrast volume: Not selected.
- Closure-device strategy: Not selected.

TEST-DATA NOTICE
This record was created solely to test ValvePath document identification, extraction,
provenance, disagreement detection, missing-data handling, formula readiness, frailty
workflow, model coverage, physician verification, and report generation. Every demographic,
clinical, laboratory, functional, and risk-score value in this file is fictional.