How should I document a cardiac diagnosis, including patient profile, presentation, exam findings, investigations, definitive diagnosis, management plan, and differential diagnoses?

Structured Approach to Documenting Cardiac Diagnoses

When documenting a cardiac diagnosis, follow this systematic order: patient demographics and risk factors, presenting symptoms with specific characteristics, focused physical examination findings, diagnostic test results (ECG, biomarkers, imaging), definitive diagnosis with severity classification, management plan, and differential diagnoses—prioritizing clinical evaluation as the cornerstone while integrating objective data to support decision-making.

Patient Profile and Risk Factor Assessment

Begin documentation by establishing the patient's baseline cardiovascular risk profile:

• Demographics: Document age, sex, and socioeconomic factors, as these influence both disease presentation and prognosis 1
• Conventional risk factors: Systematically record hypertension (defined as history of diagnosis with treatment or BP ≥140/90 mmHg on at least 2 occasions), hyperlipidemia, diabetes mellitus, smoking status, obesity, sedentary lifestyle, and family history of premature coronary artery disease 1
• Prior cardiac history: Document previous myocardial infarction (with dates of first and most recent episodes), prior revascularization procedures (CABG or PCI), documented coronary stenosis ≥50%, history of heart failure, valvular disease, cardiomyopathy (specify if ejection fraction <0.40), congenital heart disease, and arrhythmias 1
• Precipitating conditions: Note anemia, infection, fever, thyroid disorders, or other metabolic derangements that may exacerbate cardiac disease 1

Presenting Symptoms: Detailed Characterization

A careful history remains the cornerstone of cardiac diagnosis and in most cases allows confident diagnosis before objective testing 1. Document symptoms using these four critical categories:

Location and Radiation

• Typical angina: Retrosternal pressure or heaviness radiating to left arm (or both arms), neck, or jaw 1
• Atypical presentations: Epigastric pain, isolated dyspnea, or pain between shoulder blades 1
• Note that atypical complaints occur more frequently in elderly patients, women, and those with diabetes, chronic kidney disease, or dementia 1

Character and Quality

• Classic descriptors: Pressure, tightness, heaviness, strangling, constricting, or burning sensation 1
• Critical documentation point: Many patients do not experience "pain" or "pressure"—directly ask about "discomfort" 1
• Associated symptoms: Sweating, nausea, dyspnea, syncope, fatigue, faintness, or sense of impending doom 1

Duration

• Typical angina: Brief episodes lasting minutes (usually <10 minutes, commonly even less) 1
• Pitfall to avoid: Chest pain lasting only seconds is unlikely to be angina 1
• Persistent symptoms suggest acute coronary syndrome requiring immediate evaluation 1

Relationship to Exertion and Relieving Factors

• Provocation: Symptoms appear or worsen with exertion (walking uphill, against wind, in cold weather), heavy meals, or morning hours 1
• Relief: Symptoms resolve within minutes with rest or sublingual/buccal nitrates 1
• Important caveat: Nitrate relief is not specific for angina, as esophageal spasm may also respond 1
• Document "walk-through angina" or "warm-up angina" if present, and note day-to-day variability in angina threshold 1

Physical Examination: Focused Cardiac Assessment

Physical examination is frequently unremarkable in stable coronary disease but critical findings must be documented 1:

• Vital signs: Blood pressure in both arms, heart rate (elevated resting heart rate indicates worse prognosis), respiratory rate, oxygen saturation 1
• Cardiac auscultation: Document presence or absence of systolic murmurs (ischemic mitral regurgitation indicates poor prognosis), aortic stenosis, friction rub 1
• Signs of heart failure: Jugular venous distension, pulmonary rales, peripheral edema 1
• Signs suggesting alternative diagnoses: Blood pressure differences between limbs, irregular pulse, pain reproduced by palpation, pallor, tremor 1
• Pertinent negatives: Document clinically relevant negative findings specific to the differential diagnosis being considered 2

Diagnostic Investigations: Sequential Integration

Document test results in order of diagnostic workflow, integrating findings to support clinical decision-making 1:

Electrocardiogram (First-Line)

• Timing: Obtain 12-lead ECG immediately as first-line diagnostic tool 1
• Document ST-segment changes, T-wave abnormalities, Q waves indicating prior MI, conduction abnormalities, or arrhythmias 1
• Note that ECG may be normal in stable disease but abnormalities support diagnosis and provide prognostic information 1

Cardiac Biomarkers

• High-sensitivity troponin assays have higher negative predictive value and detect MI earlier than standard assays 1
• Document troponin as a quantitative marker: higher levels indicate higher likelihood of myocardial infarction 1
• Note peak creatine kinase-MB levels, as these correlate with symptom presentation patterns 3

Noninvasive Imaging

• Echocardiography: Document left ventricular ejection fraction (LVEF <0.40 indicates worse prognosis), wall motion abnormalities, valvular disease, and structural abnormalities 1
• Stress testing: Exercise ECG, pharmacological stress imaging, or exercise stress imaging to confirm ischemia 1
• Advanced imaging: Cardiac MRI or CT when indicated for structural or functional assessment 1

Invasive Testing

• Cardiac catheterization: Document number of diseased vessels, location and severity of stenoses (≥50% considered significant), and LVEF 1
• Note that worse outcomes correlate with greater number of diseased vessels, more proximal stenoses, and more extensive ischemia 1

Definitive Diagnosis with Severity Classification

State the primary cardiac diagnosis clearly, using established classification systems 1:

• For angina pectoris: Use Canadian Cardiovascular Society (CCS) classification, Califf score, or Goldman scale to grade severity 4
• For acute coronary syndromes: Distinguish between STEMI, NSTEMI, and unstable angina based on ECG findings and troponin elevation 1
• For heart failure: Document LVEF and functional class 1
• For arrhythmias: Specify type and hemodynamic significance 1

Management Plan: Algorithmic Approach

Document treatment strategy based on risk stratification 1:

Low Risk (Annual CV mortality <1%)

• Medical therapy with risk factor modification 1
• Lipid-lowering drugs, antihypertensives, antiplatelet therapy as indicated 5

Intermediate Risk (Annual CV mortality 1-2%)

• Medical therapy with close monitoring 1
• Consider coronary angiography if symptomatic control unsatisfactory 1

High Risk (Annual CV mortality >2%)

• Medical therapy AND coronary angiography for complete risk stratification 1
• Evaluate for revascularization (PCI or CABG) if high-risk coronary anatomy present 1

Specific Interventions

• Document medication regimen with specific drugs, doses, and frequencies 1
• Lifestyle modifications: smoking cessation, dietary sodium restriction, exercise program, weight management 1, 5
• Patient education regarding medication adherence, daily weight monitoring, symptom recognition 1

Differential Diagnoses: Systematic Exclusion

Document alternative diagnoses considered and excluded based on clinical evaluation 1:

• Cardiac causes: Pericarditis, myocarditis, Tako-Tsubo cardiomyopathy, aortic dissection, pulmonary embolism, valvular disease 1
• Non-cardiac causes: Esophageal spasm, gastroesophageal reflux, peptic ulcer disease, cholecystitis, pancreatitis, pneumonia, pneumothorax, musculoskeletal pain 1
• Critical pitfall: Do not attribute all symptoms to anxiety or non-cardiac causes without thoroughly excluding organic cardiac disease, especially in elderly patients with risk factors 6

Key Documentation Principles

• Prioritize accuracy over efficiency: Verify that documentation accurately reflects the actual patient encounter, avoiding cloned or boilerplate entries 2
• Focus on clinical relevance: Document pertinent positives and negatives that support diagnostic reasoning and decision-making 2
• Integrate prognostic information: Note that diagnostic and prognostic assessments occur simultaneously in practice 1
• Consider sex and demographic differences: Women, elderly patients, and those with diabetes may present atypically and require adjusted clinical suspicion 1, 3