Cardiology Visit Clinical Assessment
Structured assessment for cardiology visit documentation and AI-assisted medical reporting
Runtime Prompt for report generation
Name
First Name
Last Name
Gender
Male
Female
Patient MRN
Facility Name:
Please Select
Festival Plaza Clinic
Barsha Heights (TECOM) Clinic
Discovery Garden Clinic
JVC Clinic
Medical center where the encounter was performed
Encounter Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Encounter Type:
Please Select
Initial Consultation / Registration
Cardiac Diagnostic Test Visit
Follow-Up: Investigation Review
Follow-Up: Interval Clinical Assessment
Urgent / Unscheduled Visit
Pre-Operative Cardiac Assessment
Cardiovascular Risk Assessment
Telehealth Appointment
Select the main purpose of this patient encounter.
Purpose of Cardiac Diagnostic Test Visit
Scheduled Transthoracic Echocardiography assessment
Scheduled Treadmill Exercise Test
Scheduled Stress Echocardiography assessment
Scheduled Holter ECG monitoring
Scheduled Ambulatory Blood Pressure Monitoring
Scheduled vascular Doppler ultrasound assessment
Other
Purpose of Interval Clinical Assessment
Assessment of current or previously reported symptoms
Assessment of new or interval symptoms
Assessment of treatment response
Assessment of treatment effectiveness
Assessment of medication tolerance or possible side effects
Assessment of medication adherence
Assessment after medication initiation or adjustment
Assessment of medication-related laboratory monitoring needs
Review of home monitoring records
Assessment of blood pressure control
Assessment of lipid management and cardiovascular risk reduction
Assessment of anticoagulation therapy
Other
Subjective / Interval History – General Positive Statements
Patient reports no new clinical concerns since the previous visit.
Patient reports stable clinical condition since the previous visit.
Patient reports improvement in overall clinical condition.
Patient reports improvement in previously reported symptoms.
Patient reports no recurrence of previously reported symptoms.
Patient reports stable or improved functional capacity.
Patient reports taking medications regularly as prescribed.
Patient reports good tolerance of current treatment.
Patient reports no significant medication-related side effects.
Patient reports adherence to lifestyle and risk-factor modification advice.
Patient reports regular self-monitoring as advised.
Patient reports improvement in home monitoring parameters.
Patient reports no intercurrent emergency visit or hospitalization.
Patient attended for review and discussion of investigation results.
Patient attended for reassessment after treatment initiation or adjustment.
Patient’s questions and concerns were discussed during the visit.
Other
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ECG Findings
Date of ECG recording
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Heart Rate
QTc Interval
Heart Rhythm
Please Select
Normmal Sinus
Sinus
Sinus bradycardia
Sinus tachycardia
Atrial fibrillation
Atrial Flutter
Atrial Tachycardia
Ectopic Atrial Rhythm
QRS Axis
Please Select
Normal Axis
Left Axis
Right Axis
Undetermined Axis
Chamber Enlargement / Hypertrophy Criteria
No ECG criteria for chamber enlargement or hypertrophy
Left atrial abnormality / enlargement criteria
Right atrial abnormality / enlargement criteria
Left ventricular hypertrophy criteria
Right ventricular hypertrophy criteria
Possible left ventricular hypertrophy
Possible right ventricular hypertrophy
Intraventricular Conduction Abnormalities
No intraventricular conduction abnormality
Complete left bundle branch block (LBBB)
Incomplete left bundle branch block (ILBBB)
Complete right bundle branch block (RBBB)
Incomplete right bundle branch block (iRBBB)
Non-specific intraventricular conduction delay (IVCD)
Left anterior fascicular block (LAFB)
Left posterior fascicular block (LPFB)
Bifascicular block
QRS notching / fragmentation
QRS Notching / Fragmentation Morphology
Comment on Conduction abnormality
No evidence of conduction abnormality Observed, Normal PR interval is seen.
First degree AV block is seen
Type I Second Degree AV Block is seen
Type II Second Degree AV Block is seen
Third Degree AV Block is seen
Other
PR interval (ms)
Comment on presence of abnormal Q wave
No abnormal Q wave observed
Abnormal Q wave is present
Specification of abnormal Q wave
Comment on presence of abnormal ST segment - T wave abnormality
No abnormal ST segment - T wave abnormality observed
ST segment - T wave abnormality is present
Specification of ST segment - T wave abnormality
Comment on presence of J-Wave/ J-Point Abnormalities
No significant J-wave or J-point abnormality is observed
J-Wave / J-Point Abnormalities are present
Specification of J-Wave/ J-Point Abnormalities
Overall ECG Impression
Normal ECG
Borderline ECG
Abnormal ECG
ECG findings requiring clinical correlation
ECG findings requiring further cardiac evaluation
Additional ECG findings or comments
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Physical Examination Findings
Heart Rate (beat/min) - Resting position
Heart Rate (beat/min) - Standing position (3 minutes)
Heart Rate (beat/min) - Standing position (5 minutes)
Blood pressure
Interval Physical Examination Statement
Remainder of physical examination is unchanged from the previous visit, except as specifically documented.
Focused physical examination performed; no new clinically significant abnormal findings were noted.
Physical examination findings have changed compared with the previous visit.
Other
General Appearance
Patient appears comfortable at rest, alert, oriented, and in no acute distress.
Patient appears unwell or distressed.
Patient appears dyspneic at rest.
Patient appears pale.
Patient appears diaphoretic.
Abdominal obesity is present.
No obvious abdominal obesity.
Other
Thyroid Examination
Thyroid examination is unremarkable.
No visible thyroid enlargement.
No palpable thyroid enlargement.
Thyroid enlargement / goiter is present.
Thyroid tenderness is present.
Thyroid nodule is suspected.
Clinical features suggestive of thyroid dysfunction are present.
Heart Examination – Normal Findings
Heart examination is clinically unremarkable.
Heart rhythm is regular on auscultation.
Normal first and second heart sounds are appreciated.
No additional heart sounds are appreciated.
No clinically significant cardiac murmur is appreciated.
Jugular venous pressure is not elevated.
No clinical signs of congestive heart failure are present.
No pericardial rub is appreciated.
Peripheral perfusion appears adequate.
Heart Examination – Abnormal Findings
Irregular heart rhythm on auscultation.
Additional heart sound is present.
Cardiac murmur is present.
Raised jugular venous pressure is present.
Pericardial rub is appreciated.
Clinical signs of congestive heart failure are present.
Other
Cardiac Murmur Characterization
Lung Examination
Lungs are clear to auscultation bilaterally, with no crackles, wheeze, or reduced air entry.
Basal crackles are present.
Bilateral crackles are present.
Wheezing is present.
Other
Chest Wall Examination
Chest wall examination is unremarkable, with no localized tenderness or deformity.
Chest wall tenderness is present.
Localized reproducible chest pain is present.
Chest wall deformity is present.
Previous sternotomy scar is present.
Pacemaker / ICD pocket is present.
Pacemaker / ICD pocket appears unremarkable.
Other
Abdominal Examination
Abdomen is soft and non-tender, with no clinically evident organomegaly or ascites.
Abdominal obesity is present.
No obvious abdominal obesity.
Abdominal bruit is absent.
Abdominal bruit is present.
Hepatomegaly is suspected.
Ascites is suspected.
Abdominal tenderness is present.
Other
Carotid Examination
No carotid bruit is appreciated.
Right carotid bruit is present.
Left carotid bruit is present.
Bilateral carotid bruits are present.
Carotid pulse volume appears reduced.
Other
Edema
No peripheral edema is present.
Mild ankle edema is present.
Bilateral pretibial pitting edema is present.
Unilateral leg edema is present.
Peripheral edema is clinically significant.
Sacral edema is present.
Other
Peripheral Arterial Examination
Peripheral pulses are palpable and symmetrical bilaterally.
Peripheral extremities are warm and well perfused.
No clinical evidence of peripheral arterial insufficiency is present.
Peripheral pulse abnormality is present.
Peripheral pulses are reduced.
Peripheral pulses are asymmetrical.
Peripheral pulse is absent at one or more sites.
Peripheral extremities are cold.
Delayed capillary refill is present.
Clinical features suggestive of peripheral arterial disease are present.
Peripheral arterial pulse abnormality characterization
Lower Limb Size asymmetry / DVT Screening Findings
No significant lower limb size asymmetry
Unilateral lower limb swelling is present
Entire symptomatic leg appears swollen
Calf circumference difference is present
Calf circumference difference ≥3 cm compared with the opposite side
Pitting edema confined to the symptomatic leg
Localized tenderness along the deep venous system
Calf tenderness is present
Dilated superficial collateral veins are present
Localized redness / erythema is present
Localized warmth is present
Clinical concern for DVT
Other
Calf Circumference Measurement
Neurological Examination
Neurological examination is grossly unremarkable. The patient is alert and oriented, with clear and coherent speech, no facial asymmetry, no gross cranial nerve abnormality, no focal motor or sensory deficit, no abnormal involuntary movements, no cerebellar signs, and a steady gait.
Other
Retinal Examinations
No optic disc edema or papilledema is present.
Optic disc edema / papilledema is seen.
Generalized retinal arteriolar narrowing.
Focal retinal arteriolar narrowing.
Increased arteriolar light reflex / copper wiring.
Marked arteriolar sclerosis / silver wiring.
Arteriovenous crossing changes / AV nicking.
Retinal arteriolar tortuosity.
Retinal hemorrhages.
Flame-shaped retinal hemorrhages.
Cotton-wool spots.
Hard exudates.
Macular exudates / macular star.
Retinal edema or macular edema.
Severe hypertensive retinopathy features.
Optic Disc Edema / Papilledema Severity
Mild optic disc edema is reported, with subtle blurring of the disc margins and no documented hemorrhage or exudation.
Mild papilledema is reported, with early disc margin blurring and preserved optic disc structure.
Moderate optic disc edema is reported, with clear elevation of the optic disc and blurring of the disc margins.
Moderate papilledema is reported, with optic disc swelling and associated peripapillary retinal changes.
Severe optic disc edema is reported, with marked disc elevation and significant obscuration of the disc margins.
Severe papilledema is reported, with marked optic disc swelling and associated retinal hemorrhages, exudates, or cotton-wool spots.
Very severe papilledema is reported, with marked optic disc elevation, obscuration of retinal vessels on the disc, and significant peripapillary retinal involvement.
Optic disc edema is present; severity is not specified in the available documentation.
Findings are suspicious for optic disc edema / papilledema and require ophthalmology correlation.
Skin Examination
Skin examination is unremarkable, with no cyanosis, rash, ulceration, or peripheral stigmata of vascular disease.
Other
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Investigation Findings
Echocardiography findings
TMT findings
Ambulatory BP monitoring findings
Holter ECG monitoring Findings
Other Findings
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Lab test results
Other Lab Test Results
Results of laboratory tests
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Patient Plan – Structured Items and Justification
Cardiac Investigation Plan Items
Resting ECG
Repeat ECG
Transthoracic echocardiography (2D – Color Doppler – PW and Tissue Doppler)
Strain echocardiography (Speckle Tracking Echocardiography)
Transesophageal echocardiography
Treadmill exercise test
Stress echocardiography
Ambulatory blood pressure monitoring / ABPM
6-minute walk test: To objectively assess functional capacity, exercise tolerance, and symptom limitation during submaximal exertion.
Cardiopulmonary exercise test / CPET
24-hour Holter ECG monitoring
Extended Holter / external ECG monitoring >48 hours and <7 days
Event recorder / extended rhythm monitoring
Coronary CT angiography: To non-invasively evaluate coronary artery anatomy and assess for coronary artery disease in a clinically appropriate patient.
Cardiac CT calcium scoring: To quantify coronary artery calcium burden and support cardiovascular risk stratification, particularly when preventive treatment decisions require further risk refinement.
Conventional coronary angiography: To invasively evaluate coronary artery disease when there is high clinical suspicion, abnormal non-invasive testing, ongoing ischemic symptoms, or need for possible revascularization planning.
Cardiac MRI
Nuclear myocardial perfusion scan: To assess myocardial ischemia, perfusion abnormalities, and ischemic burden, particularly when functional ischemia evaluation is clinically indicated.
Other
Resting ECG - Reasoning / Justification
Chest pain – Assessment of rhythm, conduction, and ischemic ST-T changes.
Shortness of breath – Assessment of rhythm, conduction, ischemic changes, chamber enlargement, or strain pattern.
Palpitations – Assessment of baseline rhythm, ectopy, arrhythmia, conduction status, and QT/QTc interval.
Syncope / dizziness – Assessment of rhythm, conduction disease, bradycardia, QT/QTc abnormality, or arrhythmogenic ECG features.
Hypertension – Assessment of LVH, chamber enlargement, conduction abnormality, ischemic changes, or hypertensive heart disease pattern.
Systolic murmur – Assessment of rhythm, chamber enlargement, ventricular hypertrophy, or ECG findings suggestive of structural heart disease.
Suspected arrhythmia. To evaluate suspected arrhythmia, ectopic beats, bradycardia, tachycardia, or intermittent rhythm-related symptoms.
Repeat ECG - Reasoning / Justification
INTERVAL CHANGES. To compare with the previous ECG and assess for dynamic or INTERVAL CHANGES. To reassess previously abnormal or borderline ECG findings and determine whether the abnormality persists, resolves, or progresses
RHYTHM AND CONDUCTION STATUS. To reassess rhythm and conduction status, including heart rate, PR interval, QRS duration, QT/QTc interval, and bundle branch or fascicular conduction abnormalities.
ST – T CHANGES. To reassess ST-segment and T-wave changes in the context of chest pain, dyspnea, palpitations, syncope, or other cardiovascular symptoms.
BASELINE ASSESSMNET. To document baseline ECG status before medication initiation, dose adjustment, exercise testing, or further cardiac investigation.
QT/QTc interval. To reassess QT/QTc interval in patients receiving medications or having clinical conditions that may affect ventricular repolarization.
Strain Echocardiography - Reasoning / Justification
Enhanced functional assessment when conventional EF measurement may be insufficient, borderline, or discordant with clinical findings.
Evaluation of global longitudinal strain for early detection of subclinical myocardial dysfunction.
Follow-up of known or suspected myocardial dysfunction to assess interval change or treatment response.
Assessment of regional strain abnormalities when ischemia, scar, myocarditis, or regional myocardial disease is suspected.
Risk stratification in patients with structural heart disease, cardiomyopathy, LV hypertrophy, or abnormal echocardiographic findings.
Assessment of LV hypertrophy and hypertensive heart disease using GLS as an additional marker of myocardial involvement.
Assessment of suspected myocarditis or inflammatory myocardial involvement when subtle LV dysfunction or regional deformation abnormality is suspected.
Assessment of chemotherapy-related cardiotoxicity using GLS for early detection of myocardial dysfunction before significant EF decline.
Assessment of myocardial contractile reserve or subtle functional impairment when viability, scar-related dysfunction, or regional myocardial recovery is clinically questioned.
Transesophageal Echocardiography - Reasoning / Justification
Further evaluation of cardiac valves when transthoracic echocardiography is limited or inconclusive.
Assessment for left atrial or left atrial appendage thrombus when clinically indicated.
Evaluation of suspected infective endocarditis, vegetation, abscess, or prosthetic valve complication.
Assessment of prosthetic valve structure, function, leak, thrombosis, or endocarditis.
Evaluation of interatrial septum, atrial septal defect, patent foramen ovale, or intracardiac shunt.
Clarification of cardiac source of embolism when clinically suspected.
Treadmill Exercise Test - Reasoning / Justification
Evaluation of chest pain
Assessment of obstructive CAD (Symptom limited)
Assessment of Functional Capacity
Evaluation of exertional dyspnea suspected cardiac
Pre-OP evaluation for non-cardiac surgery
Post-PCI evaluation (stent patency assessment)
Post-CABG evaluation
Check Up (Asymptomatic)
Abnormal resting ECG requiring functional assessment
Risk stratification after myocardial infarction
Fitness assessment for occupational clearance
Exercise prescription planning
Evaluation in heart failure patients
Exercise-induced ventricular arrhythmia assessment
Evaluation of frequent PVCs
QT interval assessment during stress
Evaluation of symptoms in mild-to-moderate valvular disease
Assessment in hypertrophic cardiomyopathy
Stress Echocardiography - Reasoning / Justification
Assessment of exercise capacity, symptoms, ECG response, blood pressure response, and echocardiographic wall motion in one integrated test.
Functional assessment for inducible myocardial ischemia using stress-induced regional wall motion analysis.
Risk stratification in patients with known or suspected coronary artery disease.
Clarification of equivocal or non-diagnostic treadmill ECG findings using imaging-based ischemia assessment.
Clarification of abnormal or positive treadmill ECG findings to confirm inducible ischemia and assess regional wall motion response.
Evaluation of chest pain, exertional dyspnea, or suspected coronary artery disease when BASELINE ECG abnormalities limit reliable ST-segment interpretation.
Evaluation of chest pain, exertional dyspnea, or suspected coronary artery disease when significant LV HYPERTROPHY limits reliable interpretation of exercise-induced ST-T changes.
Evaluation of dynamic VALVULAR disease, pulmonary pressure response, or stress-induced hemodynamic changes when clinically indicated.
Assessment of myocardial CONTRACTILE RESERVE.
Assessment of myocardial VIABILITY or regional functional abnormality.
Assessment of exercise-induced DIASTOLIC dysfunction or exertional elevation of filling pressures.
Ambulatory Blood Pressure Monitoring / ABPM - Reasoning / Justification
Confirmation or exclusion of hypertension using out-of-office blood pressure assessment.
Assessment of white coat hypertension.
Assessment of masked hypertension.
Assessment of blood pressure control in treated hypertension.
Evaluation of nocturnal hypertension and dipping status.
Evaluation of resistant, uncontrolled, or suspected episodic hypertension.
Assessment before initiation, escalation, or adjustment of antihypertensive therapy.
Assessment of hypotensive episodes or suspected overtreatment in patients on antihypertensive therapy.
Cardiopulmonary Exercise Test / CPET - Reasoning / Justification
Objective assessment of functional capacity and exercise limitation.
Evaluation of unexplained dyspnea or exercise intolerance.
Differentiation of cardiac, pulmonary, peripheral, deconditioning, or mixed causes of exercise limitation.
Assessment of peak oxygen uptake, ventilatory efficiency, and cardiopulmonary reserve.
Risk stratification in heart failure, cardiomyopathy, pulmonary hypertension, or complex cardiovascular disease.
Assessment of treatment response or interval change in functional capacity.
Pre-operative, pre-rehabilitation, or exercise prescription assessment when clinically indicated.
Clarification of symptoms when resting cardiac investigations do not fully explain exercise limitation.
Holter ECG Monitoring - Reasoning / Justification
Assessment of intermittent palpitations or suspected cardiac arrhythmia.
Detection and quantification of premature ventricular contractions, and overall ectopic burden.
Assessment of bradycardia, sinus pauses, atrioventricular block, or intermittent conduction abnormalities.
Assessment of suspected tachyarrhythmia.
Evaluation of suspected atrial fibrillation, atrial flutter, or supraventricular tachycardia.
Evaluation of suspected ventricular arrhythmia.
Correlation of reported symptoms with cardiac rhythm.
Assessment of arrhythmia burden in patients with a known rhythm disorder.
Monitoring response to rate-control, rhythm-control, or antiarrhythmic therapy.
Assessment of unexplained dizziness, presyncope, syncope, or episodic symptoms when arrhythmia is suspected.
Transthoracic Echocardiography - Reasoning / Justification
Abnormal physical examination: systolic murmur – Assessment of valve structure, valve function, chamber size, ventricular function, and possible structural heart disease.
Abnormal physical examination: diastolic murmur – Assessment of suspected valvular heart disease, including valve morphology, regurgitation or stenosis severity, chamber remodeling, and hemodynamic significance.
Abnormal physical examination: S3 gallop – Assessment of LV systolic function, chamber dilatation, filling pressures, and possible heart failure physiology.
Abnormal physical examination: S4 gallop – Assessment of LV hypertrophy, diastolic function, ventricular stiffness, and hypertensive or ischemic heart disease-related structural changes.
Abnormal physical examination: mid-systolic click / suspected MVP – Assessment of mitral valve morphology, mitral valve prolapse, mitral regurgitation severity, and associated chamber remodeling.
Abnormal ECG – Echocardiographic correlation of ECG abnormalities, with assessment of cardiac structure, ventricular function, chamber size, wall thickness, and regional wall motion.
Abnormal ECG: evidence of LVH – Assessment of LV wall thickness, LV mass pattern, diastolic function, and hypertensive or structural heart disease.
Abnormal ECG: PVCs – Assessment of cardiac structure, LV/RV function, regional wall motion, and possible structural substrate for ventricular ectopy.
Abnormal ECG: atrial fibrillation – Assessment of atrial size, ventricular function, valvular disease, filling pressures, and structural contributors to atrial arrhythmia.
Chest pain – Assessment of LV function, regional wall motion abnormalities, valvular disease, pericardial disease, and structural cardiac causes of symptoms.
Palpitations – Assessment of cardiac structure, chamber size, ventricular function, valvular disease, and possible structural substrate for arrhythmia.
Exertional dyspnea – Assessment of LV/RV function, diastolic function, pulmonary pressure, valvular disease, and possible heart failure physiology.
Dizziness / syncope / near-syncope – Assessment of structural heart disease, ventricular function, valvular obstruction, cardiomyopathy, pulmonary pressure, or other cardiac contributors to symptoms.
Fatigue – Assessment of ventricular function, valvular disease, diastolic dysfunction, pulmonary pressure, and structural cardiac causes of reduced functional capacity.
Cardiac MRI - Reasoning / Justification
Assessment of ventricular size and systolic function (LV/RV)
Detection and characterization of myocardial fibrosis and scar
Evaluation of structural substrate for arrhythmia
Assessment of myocardial inflammation
Quantification of myocardial scar / fibrotic burden
Risk stratification
Evaluation and quantification of valvular regurgitation
Evaluation of myocardial viability
Assessment of myocardial infiltration
Assessment of myocardial iron deposition
Shunt detection and quantification
Evaluation of congenital heart disease
Pericardial disease evaluation, including complicated pericarditis and pericardial inflammation
Assessment of constrictive pericarditis
Evaluation of cardiac mass
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Non Cardiac Investigations
Vascular and Non-Cardiac Diagnostic Plan Items
Aortic pulse wave velocity / arterial stiffness study
Ankle-brachial index measurement / ABI
Extracranial arteries - Doppler ultrasound
Lower limb ARTERIAL Doppler ultrasound
Lower limb VENOUS Doppler ultrasound
RENAL artery Doppler ultrasound
Abdominal aorta ultrasound
Abdominal ultrasound
Liver and gallbladder ultrasound
Liver FibroScan
Retinal imaging
Sleep study for sleep-disordered breathing
Chest X ray
Ultrasound Study of Kidney - Ureters and Urinary Bladder
Vascular / Non-Cardiac Diagnostics - Reasoning / Justification
Hypertension with need for target-organ damage assessment.
Resistant or difficult-to-control hypertension.
Nocturnal hypertension or non-dipping blood pressure pattern.
Increased cardiovascular risk requiring vascular assessment.
Suspected arterial stiffness or vascular aging.
Suspected peripheral arterial disease.
Claudication or exertional leg pain.
Reduced or asymmetric peripheral pulses.
Cold lower extremity or suspected limb hypoperfusion.
Non-healing lower limb wound or ulcer.
Carotid bruit on physical examination.
Suspected carotid or extracranial arterial disease.
Neurological symptoms requiring vascular correlation.
Dizziness, syncope, or presyncope with possible vascular contribution.
Unilateral leg swelling.
Calf pain or tenderness.
Suspected deep vein thrombosis.
Lower limb edema or suspected venous insufficiency.
Suspected renovascular hypertension.
Abrupt worsening of blood pressure control.
Renal dysfunction or unexplained creatinine rise.
Creatinine rise after ACEi / ARB / ARNI therapy.
Suspected abdominal aortic aneurysm.
Abdominal bruit or pulsatile abdominal mass.
Upper abdominal pain.
Right upper quadrant abdominal pain.
Suspected gallbladder or biliary disease.
Abnormal liver enzymes.
Suspected fatty liver disease.
Obesity, metabolic syndrome, diabetes, or dyslipidemia requiring metabolic liver assessment.
Need for liver fibrosis or steatosis assessment.
Diabetes with need for microvascular target-organ assessment.
Hypertension with need for retinal end-organ assessment.
Suspected obstructive sleep apnea.
Snoring, daytime sleepiness, obesity, or unexplained fatigue.
Suspected sleep apnea contributing to hypertension or arrhythmia.
Dyspnea or suspected cardiopulmonary congestion.
Suspected heart failure, cardiomegaly, pulmonary congestion, or pleural effusion.
Respiratory symptoms requiring cardiopulmonary assessment.
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Lab Investigations
Laboratory Test Plan Items
Lipid panel (Total Cholesterol, LDL cholesterol, HDL cholesterol, Triglyceride)
Direct LDL-C
Lipoprotein(a)
Apolipoprotein B / ApoB
Serum Triglyceride
Liver enzymes / ALT, AST
Serum creatinine / EGFR
Serum cystatin C
Serum potassium
Serum sodium
Serum Magnesium
UACR
Urine albumin
Urine creatinine
Serum Uric Acid level
Urinalysis
Fasting plasma glucose / FBS
HbA1c
75-g oral glucose tolerance test / OGTT
Post-prandial / 2-hour plasma glucose
Thyroid function tests / TSH, Free T4, Free T3
Iron studies / ferritin, serum iron, transferrin, TSAT
NT-proBNP
Troponin I
D-Dimer
Complete blood count / CBC
ESR
hsCRP
PT / INR
Myopathy markers
Vasculitis markers
Antiphospholipid antibody panel
Primary hyperaldosteronism screening (Aldosterone to Plasma Renin Activity ratio)
Cushing syndrome screening
Amyloidosis workup
Pheochromocytoma assessment
Laboratory Test Requests - Reasoning / Justification
Baseline cardiovascular risk assessment.
Assessment of hypertension-related metabolic and renal risk.
Assessment of target-organ damage in hypertension.
Monitoring renal function BEFORE cardiovascular medication therapy.
Monitoring renal function DURING cardiovascular medication therapy.
Monitoring electrolytes BEFORE ACEi / ARB / ARNI, diuretic, or MRA therapy.
Monitoring electrolytes DURING ACEi / ARB / ARNI, diuretic, or MRA therapy.
Monitoring renal function and potassium AFTER medication initiation or dose adjustment.
Serum cystatin C is medically necessary to refine kidney function assessment and calculate cystatin C-based eGFR in the setting of abnormal creatinine-based eGFR. This helps confirm CKD classification, assess renal target-organ damage and cardiovascular risk, and guide safe initiation or adjustment of cardiovascular medications.
Assessment of dyslipidemia and lipid-treatment requirements.
Monitoring response to lipid-lowering therapy.
Assessment of residual cardiovascular risk.
Assessment of diabetes or prediabetes.
Assessment of glycemic control in known diabetes.
Assessment of metabolic syndrome or insulin resistance.
Assessment of obesity-related metabolic risk.
Assessment of anemia or infection/inflammation as contributor to symptoms.
Assessment of fatigue, dyspnea, palpitations, dizziness, or reduced exercise tolerance.
Assessment of thyroid dysfunction as a contributor to PRESENTING SYMPTOMS AND CLINICAL CONTEXT.
Assessment of suspected heart failure or cardiac wall-stress marker.
Assessment of acute or recent myocardial injury.
Assessment of thromboembolic risk or suspected venous thromboembolism.
Assessment of anticoagulation status or bleeding risk.
Assessment before starting or adjusting anticoagulation therapy.
Assessment of liver safety BEFORE statin or other cardiovascular medication therapy.
Assessment of liver safety DURING statin or other cardiovascular medication therapy.
Assessment of muscle symptoms or suspected statin-associated myopathy.
Assessment of inflammatory, autoimmune, or vasculitic cardiovascular disease.
Assessment of secondary causes of hypertension.
Assessment of suspected primary hyperaldosteronism.
Assessment of suspected endocrine contributor to hypertension or cardiometabolic risk.
Urine albumin-to-creatinine ratio (UACR) is requested as a BASELINE assessment of albuminuria to detect early renal target-organ damage, refine cardiovascular and renal risk stratification, and guide appropriate management in the context of hypertension, diabetes, CKD risk, or increased cardiovascular risk.
Repeat urine albumin-to-creatinine ratio (UACR) is requested to MONITOR previously abnormal albuminuria, assess persistence or progression of renal target-organ damage, evaluate treatment response, and guide ongoing cardiovascular and renal risk management.Urine creatinine is required as an integral component of urine albumin-to-creatinine ratio (UACR) calculation to quantify albuminuria accurately and assess renal target-organ damage / cardiovascular risk. It is not intended as a standalone urine creatinine test.
Assessment of iron deficiency or anemia-related cardiovascular symptoms.
Follow-up of previously abnormal laboratory results.
Pre-procedural or pre-investigation laboratory safety assessment.
Assessment for Cushing syndrome is requested to evaluate possible endogenous hypercortisolism in the context of:
Early onset Hypertension.
Resistant hypertension
Unexplained metabolic abnormalities
Obesity with Cushingoid features
Adrenal incidentaloma
Other
Cushing Syndrome Assessment Tests
T24-hour urinary free cortisol – CPT 82530.
24-hour urine creatinine – CPT 82570 – Required to assess adequacy of 24-hour urine collection for urinary free cortisol interpretation.
1-mg overnight dexamethasone suppression test: 8 AM serum cortisol – CPT 82533 – Screening for failure of cortisol suppression after low-dose dexamethasone.
Serum dexamethasone level – CPT 80299 – Optional confirmation of adequate dexamethasone exposure when suppression test validity is questioned.
Late-night salivary cortisol – CPT 82533 – Initial screening for loss of normal circadian cortisol suppression.
Late-night salivary cortisol, second sample – CPT 82533 – Repeat screening sample to improve reliability when Cushing syndrome is suspected.
Reasoning / Justification for Pheochromocytoma Assessment
Paroxysmal hypertension or episodic BP surges.
Resistant or difficult-to-control hypertension.
Episodic palpitations suggestive of catecholamine excess.
Recurrent headache associated with suspected adrenergic episodes.
Episodic diaphoresis or sweating spells.
Unexplained tachycardia or adrenergic symptoms.
Clinical suspicion of pheochromocytoma / paraganglioma based on episodic adrenergic symptoms.
Other
Pheochromocytoma Assessment Tests
Primary screening option: Plasma free fractionated metanephrines, including metanephrine and normetanephrine (CPT 83835)
Alternative urine-based screening (1): 24-hour urinary fractionated metanephrines, including metanephrine and normetanephrine → CPT 83835
Alternative urine-based screening (2): 24-hour urine creatinine for collection adequacy → CPT 82570
Adjunctive / selected-case tests (1): 24-hour urinary catecholamines → CPT 82384
Adjunctive / selected-case tests (1): Plasma catecholamines → CPT 82384
Adjunctive / selected-case tests (1): Chromogranin A → CPT 86316
Reasoning / Justification for Primary Hyperaldostronismassessment
Resistant Hypertension
Hypertension with hypokalemia
Early-onset hypertension
Family history of early-onset hypertension or stroke
Primary Aldosteronism / Hyperaldosteronism Assessment Tests
Plasma aldosterone concentration – CPT 82088
Plasma renin activity / direct renin concentration – CPT 84244
Aldosterone-to-renin ratio / ARR – CPT 82088 + 84244
24-hour urine aldosterone – CPT 82088
24-hour urine sodium – CPT 84300
24-hour urine creatinine for collection adequacy – CPT 82570
Captopril suppression test: aldosterone and renin measurements – CPT 82088 + 84244
Saline suppression test: aldosterone measurement – CPT 82088
Measurement of ApoB is requested because standard LDL-C may underestimate the patient’s exposure to atherogenic lipoprotein particles in the context of:
Elevated triglycerides.
Diabetes mellitus.
Obesity.
Metabolic syndrome.
Very low LDL-C level.
Discordance between LDL-C level and overall cardiometabolic risk.
Lipoprotein(a) / Lp(a) – Reasoning / Justification
Assessment of inherited cardiovascular risk in the setting of FAMILY HISTORY of premature ASCVD or suspected genetic risk.
Assessment of ASCVD not fully explained by major traditional risk factors.
Risk reclassification when estimated 10-year ASCVD risk is close to the moderate/high-risk treatment threshold.
Assessment of residual risk in very high-risk or statin-treated patients to guide need for more AGRESSIVE LDL-C lowering.
Serum Cystatin C – Clinical Indication / Justification
Abnormal, borderline, or discordant creatinine-based eGFR.
Need for more accurate kidney function assessment beyond serum creatinine.
Possible unreliable creatinine-based eGFR due to obesity, low muscle mass, older age, or altered body composition.
Assessment of renal target-organ involvement in hypertension, diabetes, or high cardiovascular risk.
Accurate CKD classification and cardiovascular risk stratification.
Medication safety assessment before or during cardiovascular therapy adjustment.
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Home Monitoring
Home Monitoring / Self-Monitoring Plan Items
Elevated or abnormal office BP – Home BP monitoring is recommended to confirm whether hypertension is persistent outside the clinic and to help differentiate sustained hypertension from white coat BP elevation.
Confirmation of suspected hypertension – Home BP monitoring is recommended to document out-of-office BP patterns and support accurate diagnosis before long-term treatment decisions.
Monitoring BP during treatment – Home BP monitoring is recommended to assess real-life BP control during antihypertensive therapy and guide treatment optimization.
Assessment after medication initiation or dose adjustment – Home BP monitoring is recommended to evaluate treatment response, detect hypotension or uncontrolled BP, and guide safe medication titration.
Patient hypertension self-care strategy – Home BP monitoring is recommended as part of hypertension self-management to improve patient engagement, adherence, lifestyle awareness, and timely clinical follow-up.
Continuous glucose monitoring / CGM – To assess daily glucose trends, detect glycemic variability, identify unrecognized hypo- or hyperglycemia, and guide treatment or lifestyle optimization.
Heart rate monitoring
Smartwatch / app-based rhythm monitoring – Intermittent rhythm checks, especially during symptoms.
Weight monitoring
Other
Patient Education
Patient Education – Home BP Monitoring for Patients Not Currently on Antihypertensive Treatment: The patient was educated about the role of structured home blood pressure monitoring to determine whether elevated clinic blood pressure represents persistent hypertension or a temporary/white-coat BP elevation. The patient was instructed to use a validated upper-arm BP monitor and follow the standardized measurement technique: rest quietly for 5 minutes, sit with the back supported and feet flat on the floor, keep the arm supported at heart level, and avoid caffeine, exercise, smoking, or heavy meals for at least 30 minutes before measurement. The patient was advised to measure BP at home twice in the morning and twice in the evening for 7 days, unless otherwise instructed, and to enter each reading into the clinic’s digital home BP monitoring form, including date, time, systolic BP, diastolic BP, heart rate, and any relevant symptoms or circumstances. The patient was advised not to start, stop, or self-adjust medication based on isolated readings. The submitted digital BP record will be reviewed to assess the average BP pattern, confirm or exclude sustained hypertension, determine the need for ABPM, and guide lifestyle advice or treatment planning.
Patient Education – The patient was educated that structured home blood pressure monitoring is an important part of hypertension self-care, treatment follow-up, and safe medication optimization. The patient was instructed to use a validated upper-arm BP monitor and follow the standardized measurement technique in a rested seated position. The patient was advised to enter BP readings into the clinic’s digital home BP monitoring form, including date, time, systolic BP, diastolic BP, heart rate, medication timing, missed doses, symptoms, and relevant lifestyle factors such as poor sleep, stress, high salt intake, caffeine, exercise, or illness. The patient was advised that clinical decisions should be based on BP trends and average readings rather than a single isolated value. The digital BP record will be reviewed during follow-up to assess BP control, treatment response, adherence, lifestyle triggers, possible hypotension, and need for medication adjustment. The patient was advised not to change medication doses independently unless specifically instructed, and to contact the clinic or seek urgent care if BP readings are repeatedly very high, unusually low, or associated with concerning symptoms such as chest pain, severe headache, shortness of breath, fainting, neurological symptoms, or marked dizziness.
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Follow Up Plan
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Monitoring and Follow-Up Plan Items
Review symptoms and interval clinical status. Assess new or interval symptoms
Assess: treatment RESPONSE - medication TOLERANCE - medication SIDE EFFECTS - medication adherence
Home BP log review
Request ABPM
Reassess elevated blood pressure at follow-up – Careful repeat BP assessment is required to confirm or exclude persistent hypertension, distinguish transient or clinic-related BP elevation, and guide the need for home BP monitoring, ABPM, or treatment initiation.
Request laboratory tests
Monitor kidney function and electrolytes during ACE inhibitor therapy – Required to ensure renal safety, detect hyperkalemia or creatinine rise, and guide safe continuation or dose adjustment.
Monitor kidney function and electrolytes during ARB therapy – Required to ensure renal safety, detect hyperkalemia or creatinine rise, and guide safe continuation or dose adjustment.
Monitor kidney function and electrolytes during ARNI therapy – Required to ensure renal safety, detect hyperkalemia, hypotension-related renal changes, or creatinine rise, and guide safe continuation or dose adjustment.
Monitor kidney function and electrolytes during DIURETIC therapy – Required to detect dehydration, renal function decline, hypokalemia, hyponatremia, or other electrolyte disturbances and guide dose adjustment.
Monitor kidney function and electrolytes during MRA therapy – Required to detect hyperkalemia or renal function decline and ensure safe continuation of spironolactone, eplerenone, or similar therapy.
Monitor kidney function and electrolytes during SGLT2 inhibitor therapy – Required to assess renal safety, volume status, and treatment tolerance, particularly in patients with diabetes, heart failure, or chronic kidney disease.
Monitor liver function during statin therapy
Monitor INR during warfarin therapy
Reassess lipid profile after LIFESTYLE MODIFICATION
Reassess lipid profile after PHARMACOLOGIC TREATMENT
Reassess blood pressure control and need for PHARMACOLOGIC TREATMETN
Reassess blood pressure control and need for MEDICATION ADJUSTMENT
Periodic ECHOCARIOGRAPHY follow-up
Periodic Holter ECG monitoring
Other
Long-Term Cardiovascular Risk Assessment / Risk Score Follow-Up
ASCVD Plus / PREVENT risk score assessment for long-term cardiovascular risk stratification.
SCORE2 risk assessment for estimation of 10-year fatal and non-fatal cardiovascular risk.
H2FPEF score assessment for probability of heart failure with preserved ejection fraction in patients with unexplained dyspnea or suspected HFpEF.
UKPDS risk score assessment for long-term cardiovascular risk estimation in patients with diabetes mellitus.
Risk score calculation to support shared decision-making regarding preventive cardiovascular treatment.
Referral Plan
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Medication Plan
Current Medications / Pre-Visit Medication List
Enter all medications the patient is currently taking before this visit, including dose, frequency, timing, adherence, and patient-reported use when available.
Medication Changes / Updated Treatment Plan
Enter any newly prescribed medications, discontinued medications, dose changes, frequency changes, safety instructions, monitoring requirements, and medication-related counseling.
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Addendum
Encounter transcript - Original
Encounter transcript - AI polished version
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