Management Heart Failure in Primary Care: Patient Case Form

Welcome to ECHO Idaho's Management 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

Psychosocial and Behavioral Considerations *

Describe any cognitive concerns or screening results, results of depression or anxiety screening, or barriers to care (transportation, cost, literacy).

Heart failure type

HFrEF

HFpEF

HFmrEF

NYHA functional class

I

II

III

IV

Ejection fraction (LVEF %):

Comorbidities

Need to add

example

Other...

Comorbidities Other...

Date of heart failure diagnosis:

Last HF hospitalization date

Physical Exam & Vitals

Pertinent Labs

	Normal	Abnormal
CBC	CBC - Normal	CBC - Abnormal
CMP	CMP - Normal	CMP - Abnormal
A1c	A1c - Normal	A1c - Abnormal
Lipids	Lipids - Normal	Lipids - Abnormal
TSH	TSH - Normal	TSH - Abnormal
B12	B12 - Normal	B12 - Abnormal
Vitamin D	Vitamin D - Normal	Vitamin D - Abnormal
HIV	HIV - Normal	HIV - Abnormal
RPR	RPR - Normal	RPR - Abnormal

Diagnostic Workup

Latest Labs (include date):

Current GDMT Medications

Medication Class Name Duration Current Dose Notes (Side effects/Barriers) Beta-blockers ACEIs/ARBs/ARNIs MRAs SGLT2i

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

Are there any challenges or concerns that you have regarding this patient's medication regimen (e.g., adherence, side effects, cost, drug interactions, complexity)?

No

If yes, please explain.

Are there any challenges or concerns that you have regarding this patient's medication regimen (e.g., adherence, side effects, cost, drug interactions, complexity)? If yes, please explain.

Imaging & Tests (including date):

Social History

Goals of Care

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

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

Thank you for completing ECHO Idaho's ADRD 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.

GDMT

Beta-blockers

ACEIs/ARBs/ARNIs

MRAs

SGLT2i

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