Managing Heart Failure in Primary Care: Patient Case Form

Welcome to ECHO Idaho's Managing Heart Failure in Primary Care Patient Case Submission Form.

Please complete as much of the form as you can. We understand you might not have all the data. Please do not include any specific client specific of Protected Health Information (PHI). If you have any questions regarding this form, please contact [email protected].

Presenter First and Last Name *

Credentials *

Email *

Phone Number *

Clinical Site *

City *

ECHO Idaho offers $100 in compensation for case presentations. Would you like to accept compensation for presenting this case? *

Yes (ECHO staff will reach out to you with compensation paperwork that must be completed three weeks prior to your presentation date.)

No, I would like to donate my time.

Please do not include any identifiable patient/client information, Personally Identifiable Information (PII), or Protected Health Information (PHI). If you have any questions regarding this form, please contact [email protected]. *

Click here to acknowledge.

PATIENT INFORMATION

Patient Age

Sex at Birth

Female

Male

Insurance Type

Private

Medicaid

Medicare

PRESENTING CONDITION & HISTORY

What is your primary question for the ECHO panel regarding this patient’s heart failure management or GDMT?

Date of Heart Failure Diagnosis

Heart Failure Type

HFrEF

HFpEF

HFmrEF

NYHA Functional Class

I

II

III

IV

Ejection Fraction (LVEF%)

Last HF Hospitalization Date

List Comorbidities

PHYSICAL EXAM & VITALS

Blood Pressure

mmHg

Heart Rate

bpm

Weight

lb

Jugular Vein Distention

Yes

No

Peripheral Edema

Yes

No

Lung Auscultation Findings Other...

CURRENT GDMT MEDICATIONS

Beta-blocker

Yes

No

Name of Beta Blocker

Reason for no Beta Blocker

Duration of Beta Blocker

Current Dose of Beta Blocker

Beta Blocker Considerations (e.g., adherence, side effects, cost, drug interactions, complexity)

ACEIs/ARBs/ARNIs

Yes

No

Reason for no ACEIs/ARBs/ARNIs

Name of ACEIs/ARBs/ARNIs

Duration of ACEIs/ARBs/ARNIs

Current Dose of ACEIs/ARBs/ARNIs

ACEIs/ARBs/ARNIs Considerations (e.g., adherence, side effects, cost, drug interactions, complexity)

MRAs

Yes

No

Reason for no MRA

Name of MRAs

Duration of MRAs

Current Dose of MRAs

MRA Considerations (e.g., adherence, side effects, cost, drug interactions, complexity)

SGLT2i

Yes

No

Reason for no SGLT2i

Name of SGLT2i

Duration of SGLT2i

Current Dose of SGLT2i

SGLT2i Considerations (e.g., adherence, side effects, cost, drug interactions, complexity)

Please list other medications used (indicate past or current if known)

LABS, IMAGING & TEST RESULTS

Provide date & results of the following if known.

BNP/NT-proBNP

Creatinine/BUN

Potassium/Sodium

Magnesium/Calcium

TSH/A1c/Lipids

Echocardiogram

No

If yes, include date:

Echocardiogram If yes, include date:

Cardiac MRI

No

If yes, include date & results:

Cardiac MRI If yes, include date & results:

Other Imaging

No

If yes, include date & results:

Other Imaging If yes, include date & results:

Identify any implanted cardiac devices this patient has

ICD (Implantable Cardioverter Defibrillator)

CRT-P (Cardiac Resynchronization Therapy – Pacemaker)

CRT-D (Cardiac Resynchronization Therapy – Defibrillator)

Other...

Identify any implanted cardiac devices this patient has Other...

ADDITIONAL CONTEXT

Social History

Advance Directives/Code Status Discussed

Yes

No

Goals of Care

What is important to the patient/family (physical, psychological, emotional, social, spiritual care)?

Thank you for completing ECHO Idaho's Managing Heart Failure in Primary Care Case Submission Form:

Case consultations do not create or otherwise establish a provider-patient relationship between any clinician and any patient whose case is being presented in this clinical setting.
No personally identifiable health information (PHI) or personally identifiable information (PII) appears in answers on the above form, in compliance with HIPAA privacy laws.

You will receive a copy of your responses in the email you provided and be contacted by ECHO staff about presenting your case in a session or follow-up consultation with a panelist within two business days.

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