PREVENT™ │ Carevala, LLC │ CONFIDENTIAL C.T. │ PCT-20251001-CT71 │ October 2025

PREVENT™

PATIENT JOURNEY REPORT

Active Monitoring Record │ October 2025

Patient Identifier: C.T.

Age 71 │ Male │ Miami, Florida │ Medicare Primary

Monitoring Tier: Moderate │ Enrolled: October 1, 2025

CARE TEAM

T.R., Patient Care Specialist │ M.B., RDN │ J.T., CDE │ D.L., Pharmacy Technician │ Dr. M.W., Supervising Physician

Carevala, LLC │ West Palm Beach, Florida │ CONFIDENTIAL CLINICAL RECORD │ October 2025

PREVENT™ │ CAREVALA, LLC │ ENROLLMENT & TIER ASSIGNMENT

Patient: C.T. │ PCT-20251001-CT71

To: T.R., PCS │ Dr. M.W.

Report ID: ENR-20251001-CT71

Generated: October 1, 2025 │ 07:02:11

Priority: Moderate — Pending Device Confirmation

Status: ENROLLMENT COMPLETE

PATIENT PROFILE INGESTED

Field	Value
Patient Identifier	C.T.
Age / Sex	71 / Male
Location	Miami, Florida
Enrollment Date	October 1, 2025
Referring Physician	Dr. M.W.
Insurance	Medicare — Primary
Patient ID	PCT-20251001-CT71

CHRONIC CONDITIONS ENTERED AT ENROLLMENT

ICD-10	Condition	PREVENT™ Mapped	Risk Weight
E11.65	Type 2 Diabetes Mellitus with hyperglycemia	Yes	High
E11.40	Diabetic neuropathy, unspecified	Yes	High
I10	Essential (primary) hypertension	Yes	Moderate
N18.2	Chronic kidney disease, Stage 2	Yes	Moderate
Z87.39	Personal history of cardiovascular conditions	Yes	Moderate

PREVENT™ TIER ASSIGNMENT — REASONING

PREVENT™ CLINICAL REASONING

▸ Patient age 71. Age modifier: patients ≥65 receive a +5 composite risk score adjustment.

▸ Four mapped chronic conditions. Base score: 4 × 10 = 40 points.

▸ T2DM with neuropathy (E11.40): compound condition. Neuropathy subtype adds vascular risk modifier (+8 pts). Compound score: 18 points.

▸ Hypertension co-occurring with CKD Stage 2: renal-cardiovascular coupling detected. Co-occurrence amplifier: +6 points.

▸ Cardiovascular history (Z87.39): activates secondary cardiovascular screening pathway. +3 points.

▸ Age modifier: +5 points.

▸ Composite Risk Score: 40 + 18 + 6 + 3 + 5 − 2 (no prior hospitalization) = 70 points.

▸ Score 60–79 = MODERATE TIER. Score ≥80 = Complex Tier. Score < 60 = Standard Tier.

▸ Assignment: MODERATE TIER. Re-evaluation at 30-day assessment. Device findings may trigger escalation to Complex Tier.

ℹ CLINICAL NOTICE

Tier assignment preliminary pending device findings. MESI mTABLET and VitalScan results may trigger upward revision. See Tier Escalation Notice.

PREVENT™ │ CAREVALA, LLC │ DEVICE & BIOMARKER RECOMMENDATION ORDER

Patient: C.T. │ PCT-20251001-CT71

To: T.R., PCS │ D.L., Pharmacy Tech │ Dr. M.W.

Report ID: ORD-20251001-CT71-001

Generated: October 1, 2025 │ 07:02:14

Priority: Moderate

Status: ORDER ISSUED — PENDING DEPLOYMENT

RECOMMENDED DEVICE DEPLOYMENTS

Device	Clinical Purpose	Trigger Condition	Priority
MESI mTABLET ABI/TBI	Peripheral arterial disease screening via Ankle-Brachial Index and Toe-Brachial Index	T2DM + peripheral neuropathy + age ≥65	Immediate — Enrollment Exam
VitalScan	12-lead resting ECG + heart rate variability + autonomic nervous system assessment	Hypertension + cardiovascular history + T2DM	Immediate — Enrollment Exam
CardioSet	At-home daily thoracic impedance monitoring for early pulmonary congestion detection	Hypertension + CKD Stage 2 + cardiovascular history	Deploy at enrollment — daily home use
Dexcom G7 (CGM)	Continuous interstitial glucose monitoring — real-time trend, variability, time-in-range	T2DM with active hyperglycemia (E11.65)	Deploy at enrollment — 10-day wear

PREVENT™ CLINICAL REASONING

▸ MESI mTABLET — TBI selected over ABI alone: medial arterial calcification is prevalent in long-duration T2DM patients and artificially elevates ABI, producing false-normal results. Toe vessels are substantially less susceptible to calcification. TBI is the clinically validated vascular index for this patient profile.

▸ VitalScan — autonomic assessment selected: diabetic cardiac autonomic neuropathy (CAN) affects cardiac innervation and is associated with silent myocardial ischemia, orthostatic hypotension, and increased all-cause mortality. Standard office ECG does not assess heart rate variability.

▸ CardioSet — thoracic impedance selected: CKD Stage 2 with hypertension creates a fluid retention risk profile. Early impedance decline precedes symptomatic pulmonary edema by 10–14 days. Home monitoring enables intervention before hospitalization threshold is reached. FDA cleared September 2025.

▸ Dexcom G7 — CGM selected over HbA1c alone: HbA1c reflects 90-day average and misses postprandial excursions, nocturnal hypoglycemia, and glucose variability — all independently associated with cardiovascular and renal complications in T2DM.

RECOMMENDED BIOMARKER PANEL — FOR PHYSICIAN AUTHORIZATION

Layer	Biomarkers	Clinical Rationale	Draw Timing
Layer 1 — Metabolic	HbA1c, Fasting Glucose, Fasting Insulin, HOMA-IR	Glycemic control baseline and insulin resistance quantification.	Enrollment — fasting
Layer 2 — Lipid	Full lipid panel, ApoB, Lp(a), Non-HDL Cholesterol	ApoB and Lp(a) provide cardiovascular risk data not captured by standard lipid panel.	Enrollment — fasting
Layer 3 — Renal	eGFR, BMP, UACR	CKD Stage 2 monitoring. UACR is the earliest marker of diabetic nephropathy progression.	Enrollment
Layer 4 — Hepatic	ALT, AST, GGT, Ferritin, FIB-4 Score	T2DM patients carry 2–3× elevated NAFLD/MASLD prevalence.	Enrollment
Layer 5 — Inflammatory	hsCRP, Fibrinogen	Elevated hsCRP in T2DM is an independent cardiovascular risk factor beyond LDL.	Enrollment
Layer 6 — Thyroid	TSH, Free T4	Thyroid dysfunction amplifies T2DM metabolic dysregulation.	Enrollment
Layer 7 — Hormonal	Total Testosterone, SHBG, Free Androgen Index	Hypogonadism in males with T2DM independently worsens insulin resistance and cardiovascular risk.	Enrollment
Layer 8 — Nutritional	25-OH Vitamin D, Magnesium, Zinc	All three deficiencies independently worsen glycemic control in T2DM.	Enrollment

All biomarker orders require physician authorization. Dr. M.W. retains full clinical authority.

PREVENT™ │ CAREVALA, LLC │ PCS WORK ORDER

Patient: C.T. │ Age 71 │ Miami, FL

To: T.R., Patient Care Specialist

Report ID: WO-20251001-CT71-TR

Generated: October 1, 2025 │ 07:02:16

Priority: Moderate

Status: ASSIGNED — ACTION REQUIRED

T.R. — You are C.T.’s first point of contact. PREVENT™ has assigned this patient Moderate Tier (composite risk score 70/100). Your enrollment encounter is the platform’s first real-world data collection point. Everything you observe, deploy, and document becomes the clinical record Dr. M.W. acts on.

DEVICES TO DEPLOY — THIS ENCOUNTER

Device	Your Action	Why PREVENT™ Ordered It
MESI mTABLET	Perform bilateral ABI and TBI. Brachial pressures first, then ankle, then toe. Record all values. Photograph any visible foot abnormality.	C.T. has T2DM with neuropathy. ABI is unreliable in diabetic patients. TBI is the correct vascular index. This test may identify PAD that has never been diagnosed.
VitalScan	Apply leads per protocol. Full ECG and HRV assessment. Patient seated, relaxed, still for minimum 5 minutes prior to measurement.	Hypertension and cardiovascular history. Diabetic autonomic neuropathy can be silent. VitalScan detects autonomic dysfunction not visible on standard ECG.
CardioSet	Set up home device. Walk C.T. and wife through daily measurement routine. Confirm independent operation. Record baseline impedance reading before leaving.	CKD Stage 2 with hypertension. Fluid shifts can be pre-symptomatic. Today’s baseline is required for all future trend comparisons.
Dexcom G7	Apply sensor upper arm per protocol. Set alerts: low 70 mg/dL, high 250 mg/dL. Enable share to wife’s smartphone if she consents. Confirm PREVENT™ transmission before leaving.	Active hyperglycemia. CGM captures postprandial spikes, nocturnal patterns, and variability that fingerstick and HbA1c miss.

WHAT TO OBSERVE AND DOCUMENT

Foot and Lower Extremity:

Inspect both feet — skin color, temperature, hair loss, ulceration, calluses, nail condition.
Ask when C.T. last had a foot exam at a physician’s office.
Ask if he experiences leg cramping when walking that resolves with rest. Duration, frequency, which leg.
Ask about numbness, tingling, or burning in feet or legs.
Photographs required if any skin change, wound, or deformity is present.

General Clinical Observation:

Note mobility, gait stability, and ability to manage devices independently.
Observe medication organization. Confirm wife’s management role. Document as care asset.
Ask about hospitalizations or ER visits in the past 12 months.

ESCALATION THRESHOLDS — CALL DR. M.W. IMMEDIATELY

⚠ HIGH PRIORITY ALERT

MESI mTABLET TBI < 0.60 in either foot — critical PAD range.

VitalScan flags atrial fibrillation, ST-segment abnormality, or QTc > 500 ms.

Patient reports chest pain, shortness of breath, or recent unexplained syncope.

Any open wound, ulceration, or active skin breakdown on lower extremities.

WHAT TO SEND BACK TO PREVENT™ AFTER THIS ENCOUNTER

All device measurement outputs.
Completed foot and lower extremity observation notes.
CardioSet baseline impedance value confirmed.
CGM sensor placement confirmed and PREVENT™ transmission verified.
Wife consent for CGM share feature — Yes / No / Declined.
Any escalation flags triggered — document action taken and time of physician contact.
Patient and caregiver engagement level — 1 to 5 scale.

PREVENT™ │ CAREVALA, LLC │ DEVICE REPORT — MESI MTABLET ABI/TBI

Patient: C.T. │ Age 71 │ Male

To: Dr. M.W. │ T.R., PCS │ Clinical Record

Report ID: DEV-20251001-CT71-MESI

Generated: October 1, 2025 │ 09:47:22

Priority: HIGH — Abnormal Result

Status: RESULT RECEIVED — PHYSICIAN REVIEW REQUIRED

EXAMINATION DETAILS

Field	Value
Performed By	T.R., PCS — PREVENT™ Certified Operator
Date / Time	October 1, 2025 │ 09:31 – 09:46
Device	MESI mTABLET │ Serial No. MESI-4471-B │ Calibration current
Protocol	Bilateral ABI + Bilateral TBI — simultaneous oscillometric measurement
Patient Position	Supine, 5-minute rest prior to first cuff inflation
Room Temperature	72°F (22°C)

SYSTOLIC PRESSURE MEASUREMENTS (MMHG)

Measurement Point	Right (mmHg)	Left (mmHg)	Clinical Note
Brachial — Upper Arm (averaged ×2)	148	144	Reference standard. Two readings averaged per protocol.
Ankle — Posterior Tibial	162	158	Elevated vs. brachial. Medial arterial calcification pattern. Non-diagnostic for PAD.
Ankle — Dorsalis Pedis	157	154	Elevated. Calcification pattern consistent. Non-diagnostic.
Toe — First Digit	92	116	Right: significantly reduced. Left: normal range. Unilateral right-side disease.

CALCULATED INDICES

Index	Right	Left	Reference Range	Interpretation
Ankle-Brachial Index (ABI)	1.09	1.08	≥0.90 = Normal	Non-diagnostic in this patient. ABI in normal range does not exclude PAD in T2DM patients with medial calcification.
Toe-Brachial Index (TBI)	0.62	0.81	≥0.70 = Normal / <0.70 = PAD	RIGHT: 0.62 — PAD CONFIRMED. LEFT: 0.81 — Normal. Unilateral right lower extremity peripheral arterial disease.

⚠ HIGH PRIORITY ALERT

TBI RIGHT FOOT: 0.62 — BELOW DIAGNOSTIC THRESHOLD OF 0.70. PERIPHERAL ARTERIAL DISEASE CONFIRMED.

ABI was 1.09 (normal range) — demonstrating precisely why ABI is unreliable in diabetic patients. Without TBI, this PAD finding would have been missed and C.T. would have been incorrectly cleared.

Left TBI 0.81 — normal. Unilateral right-side disease. Vascular asymmetry documented.

WAVEFORM ANALYSIS BY SEGMENT

Segment	Right Waveform	Left Waveform	Clinical Significance
Femoral	Triphasic	Triphasic	Normal proximal inflow bilaterally. Aortoiliac segment clear.
Popliteal	Triphasic	Triphasic	Normal mid-segment flow bilaterally.
Posterior Tibial	Biphasic	Triphasic	Right: mild dampening. Increased distal resistance.
Dorsalis Pedis	Biphasic	Triphasic	Right: waveform dampening consistent with distal arterial disease.
Digital — First Toe	Monophasic	Biphasic	Right: MONOPHASIC — confirms significant distal flow reduction. Diagnostic of PAD.

FOOT OBSERVATION NOTES — T.R., PCS

Observation	Findings — October 1, 2025
Skin Color — Right	Pallor on plantar surface. No erythema or cyanosis.
Skin Color — Left	Normal coloration.
Skin Temperature	Right foot cooler than left on palpation. Consistent with reduced arterial inflow.
Hair Distribution	Absent: right great toe, dorsal right foot, right lower leg below mid-calf. Consistent with chronic ischemia pattern.
Nail Condition	Thickened nails bilaterally. Onychomycosis pattern noted right great toe.
Wounds / Ulcerations	None present at time of examination.
Calluses	Plantar callus present on right heel.
Claudication History	Patient reports right leg cramping walking more than two blocks. Resolves with rest. Present for extended period — attributed to aging and not previously reported to physician.

PREVENT™ CLINICAL REASONING

▸ The combination of TBI 0.62, monophasic digital waveform, pallor, reduced skin temperature, absent hair distribution on right lower extremity, and patient-reported claudication constitutes a complete peripheral arterial disease clinical presentation.

▸ This condition was not documented in C.T.’s existing medical record prior to this PREVENT™ enrollment examination.

▸ Classic intermittent claudication — cramping with ambulation resolving with rest — was present but unreported. The patient normalized the symptom as age-related fatigue. PREVENT™ structured questioning surfaced it.

▸ Monophasic digital waveform combined with TBI < 0.70 places C.T. at elevated risk for non-healing wounds, foot ulceration, and limb-loss events if vascular disease progresses without intervention.

PREVENT™ │ CAREVALA, LLC │ DEVICE REPORT — VITALSCAN CARDIAC & AUTONOMIC

Patient: C.T. │ Age 71 │ Male

To: Dr. M.W. │ Clinical Record

Report ID: DEV-20251001-CT71-VS

Generated: October 1, 2025 │ 10:03:45

Priority: Moderate — Abnormal Autonomic Finding

Status: RESULT RECEIVED — PHYSICIAN REVIEW REQUIRED

EXAMINATION DETAILS

Field	Value
Performed By	T.R., PCS — PREVENT™ Certified Operator
Date / Time	October 1, 2025 │ 09:52 – 10:03
Device	VitalScan │ Serial No. VS-8812-A │ Firmware v4.2.1
Protocol	Resting 12-lead ECG + 5-minute HRV recording + Autonomic Reflex Battery
Patient Condition	Seated, resting 5 minutes prior. No caffeine within 4 hours. No recent exertion.

RESTING ECG RESULTS

Parameter	Measured Value	Reference Range	Status
Heart Rate	64 bpm	60–100 bpm	Normal
PR Interval	182 ms	120–200 ms	Normal
QRS Duration	94 ms	< 120 ms	Normal
QTc Interval (Bazett)	441 ms	< 450 ms (male)	Normal — upper boundary. Monitor for QTc-prolonging meds.
ST Segment	No deviation detected	±1 mm	Normal
T-Wave Morphology	Normal axis and amplitude	Upright I, II, V4–V6	Normal
Cardiac Rhythm	Normal sinus rhythm	Regular sinus	Normal
Electrical Axis	+42°	−30° to +90°	Normal

HEART RATE VARIABILITY (HRV) — 5-MINUTE RECORDING

HRV Parameter	Definition	Measured Value	Age-Matched Reference (65–75 Male)	Status
SDNN	Standard deviation of all RR intervals — total autonomic modulation	22 ms	38–68 ms	BELOW NORMAL
RMSSD	Root mean square of successive RR differences — vagal / parasympathetic tone	11 ms	20–40 ms	BELOW NORMAL
LF Power	Low-frequency spectral power — sympathetic modulation	312 ms²	400–1,200 ms²	Reduced
HF Power	High-frequency spectral power — parasympathetic modulation	98 ms²	200–800 ms²	Reduced
LF/HF Ratio	Sympathovagal balance index	3.18	1.5–3.0	Mildly elevated
pNN50	Percentage of successive RR intervals differing > 50 ms	3.2%	8–18%	BELOW NORMAL
Total Power	Overall HRV spectral power	428 ms²	800–2,500 ms²	Reduced

● MODERATE ALERT

CARDIAC AUTONOMIC NEUROPATHY PATTERN CONFIRMED. SDNN 22 ms and RMSSD 11 ms are both below age-matched reference ranges, consistent with diabetic cardiac autonomic neuropathy (CAN).

CAN in T2DM is associated with: silent myocardial ischemia, increased cardiovascular mortality, exercise intolerance, and orthostatic hypotension.

QTc 441 ms — within normal limits but approaching upper boundary. Flag for QTc-prolonging medications in pharmacy reconciliation.

No acute arrhythmia detected. No ST-segment changes. Structural ECG is normal. The pathology is autonomic, not structural.

PREVENT™ CLINICAL REASONING

▸ VitalScan was ordered by PREVENT™ because T2DM with neuropathy is a recognized risk factor for cardiac autonomic neuropathy. Standard office 12-lead ECG does not assess HRV and would not have detected this finding.

▸ The combination of peripheral autonomic dysfunction (confirmed by monophasic waveform on MESI exam) and cardiac autonomic neuropathy confirmed here establishes a systemic diabetic autonomic neuropathy pattern in C.T.

▸ Formal cardiovascular autonomic reflex testing (CART) is recommended to confirm the CAN diagnosis. CART results will guide cardiovascular surveillance intensity and cardiology referral decision.

▸ CAN is an independent predictor of cardiovascular mortality in T2DM, with a hazard ratio of approximately 3.65 in published meta-analyses.

PREVENT™ │ CAREVALA, LLC │ DEVICE REPORT — CARDIOSET THORACIC IMPEDANCE BASELINE

Patient: C.T. │ Age 71 │ Male

To: Dr. M.W. │ Clinical Record

Report ID: DEV-20251001-CT71-CS

Generated: October 1, 2025 │ 10:28:17

Priority: Moderate — Baseline Established

Status: BASELINE RECORDED — TREND MONITORING ACTIVE

CardioSet received FDA clearance in September 2025. This report documents C.T.’s enrollment baseline measurement. All future readings will be compared against these values. PREVENT™ will generate a physician alert if thoracic impedance declines ≥8% from baseline over any 7-day rolling window.

BASELINE MEASUREMENT — OCTOBER 1, 2025

Parameter	Value
Thoracic Impedance — Baseline	31.4 Ω (Ohms)
Normal Reference Range — Male 65–75	28.0 – 38.0 Ω
Alert Threshold — 8% Decline	< 28.9 Ω
Alert Threshold — 12% Decline (urgent)	< 27.6 Ω
Measurement Time	07:12 — morning, pre-ambulation
Body Position	Seated upright — standardized position protocol established
Device Placement Verified	Yes — T.R. confirmed electrode placement per CardioSet protocol
Wife Observed Protocol	Yes — wife observed and confirmed ability to assist daily
30-Day Monitoring Status	Active — readings transmitting to PREVENT™ platform every morning

MEASUREMENT PROTOCOL ESTABLISHED

Patient to measure every morning before getting out of bed.
Consistent seated upright position required. Variation in position affects impedance values.
Same electrode placement each day. Wife confirmed as placement supervisor.
Readings transmit automatically to PREVENT™ platform within 5 minutes of measurement.
If device fails to transmit for two consecutive days, T.R. receives a PREVENT™ platform alert.

CLINICAL CONTEXT — WHY THIS MATTERS FOR C.T.

PREVENT™ CLINICAL REASONING

▸ C.T. presents with hypertension, CKD Stage 2, and cardiovascular history. This combination creates a fluid retention risk profile that can develop silently.

▸ Symptomatic pulmonary edema typically presents when thoracic fluid burden is already significant. Impedance monitoring detects the pre-symptomatic decline — typically 10–14 days before clinical symptoms appear.

▸ Early detection enables physician-directed diuretic adjustment or clinical evaluation before C.T. reaches emergency presentation threshold.

▸ CardioSet baseline of 31.4 Ω is within normal range. Trend monitoring is the clinical value — not the absolute number. A decline of 8% or more from this individual baseline is the actionable threshold.

PREVENT™ │ CAREVALA, LLC │ DEVICE REPORT — DEXCOM G7 CGM DEPLOYMENT

Patient: C.T. │ Age 71 │ Male

To: J.T., CDE │ M.B., RDN │ Dr. M.W.

Report ID: DEV-20251001-CT71-CGM

Generated: October 1, 2025 │ 11:05:00

Priority: Moderate

Status: SENSOR ACTIVE — DATA TRANSMITTING

DEPLOYMENT DETAILS

Parameter	Value
Sensor Applied	October 1, 2025 │ 10:52
Sensor Location	Posterior upper arm — right
Sensor Warmup Complete	12:52 (2-hour warmup period)
First Live Reading	147 mg/dL │ 12:53 (approximately 3 hours post-breakfast)
Alert — Urgent Low	55 mg/dL
Alert — Low	70 mg/dL
Alert — High	250 mg/dL
Share Feature	Enabled — wife’s smartphone connected and confirmed receiving data
Platform Transmission	PREVENT™ data feed active — readings every 5 minutes
Wear Duration	10-day sensor. Replacement date: October 11, 2025.

DAYS 1–7 SUMMARY — CGM DATA RECEIVED

Metric	Value	Target	Status
Time in Range (70–180 mg/dL)	54%	≥70%	Below target
Time Above Range (> 180 mg/dL)	38%	< 25%	Elevated
Time Below Range (< 70 mg/dL)	2%	< 4%	Acceptable
Time Below Range (< 54 mg/dL)	0%	< 1%	Normal
Average Glucose	172 mg/dL	< 154 mg/dL (est. HbA1c 7.0%)	Elevated
Glucose Management Indicator (GMI)	7.6%	< 7.0%	Above target
Coefficient of Variation (CV)	38%	< 36%	Mildly elevated variability
Highest Reading Recorded	286 mg/dL at 08:45 Oct 3	< 250 mg/dL	Excursion noted

PREVENT™ CLINICAL REASONING

▸ Postprandial glucose excursions exceeding 180 mg/dL concentrated in the 08:00–10:00 window, consistent with high-glycemic breakfast composition. Pattern reviewed by M.B., RDN.

▸ Time-in-range of 54% is below the ADA/EASD recommended target of 70% or greater for older adults with T2DM.

▸ GMI of 7.6% is an estimated HbA1c equivalent derived from CGM data. More reflective of recent glycemic status than a drawn HbA1c for short-term monitoring.

▸ Coefficient of Variation of 38% indicates mildly elevated glucose variability. High variability independently associated with hypoglycemia risk and oxidative stress.

PREVENT™ │ CAREVALA, LLC │ BIOMARKER LAB RESULTS REPORT

Patient: C.T. │ PCT-20251001-CT71

To: Dr. M.W. │ Clinical Record

Report ID: LAB-20251003-CT71

Generated: October 3, 2025 │ Results Received 14:22

Priority: Moderate — Multiple Flags

Status: RESULTS FILED — PHYSICIAN REVIEW REQUIRED

Fasting draw performed October 3, 2025 at 07:30. Results received by PREVENT™ platform at 14:22. Flagged values transmitted to Dr. M.W. via Physician Report and Direct Message.

LAYER 1 — METABOLIC

Biomarker	Result	Reference Range	Flag	Clinical Note
HbA1c	7.8%	< 7.0% (ADA target T2DM)	ABOVE TARGET	Correlates with GMI 7.6% from CGM. Active glycemic management needed.
Fasting Glucose	148 mg/dL	70–99 mg/dL	ELEVATED	Consistent with HbA1c. CGM providing real-time management data.
Fasting Insulin	18.4 μIU/mL	2.6–24.9 μIU/mL	Normal	Upper normal range. Interpret with HOMA-IR.
HOMA-IR	6.8	> 2.5 = insulin resistance	ELEVATED	Confirms significant insulin resistance. Important for endocrinologist review.

LAYER 2 — LIPID & CARDIOMETABOLIC

Biomarker	Result	Reference Range	Flag	Clinical Note
Total Cholesterol	198 mg/dL	< 200 mg/dL	Normal	Borderline. Interpret with particle data.
LDL Cholesterol	118 mg/dL	< 70 mg/dL (PAD patient)	ABOVE TARGET	PAD confirmed. LDL target for PAD per ACC/AHA: < 70 mg/dL. Atorvastatin 20 mg insufficient.
HDL Cholesterol	38 mg/dL	< 40 mg/dL (male risk)	LOW	Low HDL is an independent cardiovascular risk factor.
Triglycerides	218 mg/dL	< 150 mg/dL	ELEVATED	Consistent with insulin resistance (HOMA-IR 6.8). Atherogenic dyslipidemia pattern.
ApoB	112 mg/dL	< 80 mg/dL (high-risk)	ELEVATED	ApoB superior to LDL for cardiovascular risk in T2DM. 112 mg/dL = significant particle burden.
Lp(a)	62 mg/dL	< 30 mg/dL	ELEVATED	Lp(a) > 50 mg/dL is an independent cardiovascular risk factor not modifiable by statins.
Non-HDL Cholesterol	160 mg/dL	< 100 mg/dL (PAD)	ELEVATED	Reflects total atherogenic particle burden. Significantly above PAD target.

LAYER 3 — RENAL

Biomarker	Result	Reference Range	Flag	Clinical Note
eGFR	62 mL/min/1.73m²	60–89 = CKD Stage 2	Confirms CKD Stage 2	Metformin acceptable. Reassess if eGFR declines below 45.
Creatinine	1.18 mg/dL	0.74–1.35 mg/dL	Normal	Within range for age.
BUN	22 mg/dL	7–25 mg/dL	Normal	Normal.
UACR	48 mg/g	< 30 = normal / 30–300 = microalbuminuria	MICROALBUMINURIA	Early diabetic nephropathy marker. ACE inhibitor optimization relevant.
Potassium	4.2 mEq/L	3.5–5.1 mEq/L	Normal	Monitor given ACE inhibitor and diuretic co-use.

LAYERS 4–8 — SUMMARY FLAGS

Layer	Key Result	Flag	Action
Layer 4 — Hepatic	ALT 52 U/L (ref < 40), AST 44 U/L (ref < 40), GGT 68 U/L (ref < 50), FIB-4 Score 1.6	MILD ELEVATION	FIB-4 1.6 is indeterminate (1.3–2.67). Borderline MASLD risk in T2DM context. Monitor.
Layer 5 — Inflammatory	hsCRP 4.8 mg/L (ref > 3 = high CV risk), Fibrinogen 412 mg/dL (ref 200–400)	ELEVATED — High CV risk	hsCRP 4.8 mg/L = high cardiovascular inflammatory risk. Statin intensification partially addresses.
Layer 6 — Thyroid	TSH 2.1 mIU/L (ref 0.4–4.0), Free T4 1.1 ng/dL (ref 0.8–1.8)	Normal	No thyroid contribution to metabolic dysregulation.
Layer 7 — Hormonal	Total Testosterone 312 ng/dL (ref 300–1,000), SHBG 28 nmol/L	LOW-NORMAL	Testosterone at lower boundary of normal. Clinical judgment required.
Layer 8 — Nutritional	25-OH Vitamin D 18 ng/mL (ref 30–50 optimal), Magnesium 1.9 mg/dL, Zinc 74 μg/dL	VITAMIN D DEFICIENT	Vitamin D 18 ng/mL is deficient. Associated with worsened insulin resistance in T2DM. Supplementation recommended.

PREVENT™ │ CAREVALA, LLC │ PCS FIELD NOTES — T.R.

Patient: C.T. │ PCT-20251001-CT71

To: Medical Scribe │ PREVENT™ Platform

Report ID: PCS-20251001-CT71-TR

Generated: October 1, 2025 │ Submitted 11:41

Priority: Moderate

Status: FILED — PENDING SCRIBE CONDENSATION

Note: These are the raw field notes submitted by T.R. following the October 1, 2025 enrollment encounter. These notes will be condensed by the PREVENT™ medical scribe service into a structured clinical note for physician review and co-signature.

T.R. RAW FIELD NOTES — OCTOBER 1, 2025

C.T. and his wife arrived for the enrollment encounter at 08:55. C.T. ambulating independently, no assistive device. Gait slow but steady. Appeared in good spirits. Wife very engaged and clearly manages medication organization — medications laid out in a weekly pill organizer, organized by day and time.

Started with VitalScan. Had C.T. sit and rest about 5-6 minutes before I applied leads. He was patient and relaxed. Device ran without issues. He asked what it was doing and I explained it was looking at his heart rhythm and how his nervous system is working. He said his doctor never did that kind of test. Device completed around 10:03.

Moved to MESI mTABLET. Explained the test. Did brachial both arms first, then ankle cuffs, then toe cuffs. C.T. was completely relaxed. When I was placing the toe cuffs I noticed right away that his right foot felt noticeably cooler than the left. Also noticed no hair on his right lower leg or toes on the right side. Left side had some hair. Made a note.

Asked C.T. about his legs during the exam. He mentioned that he gets cramps in his right leg when he walks more than a couple blocks. Goes away when he stops. He said he figured it was just getting older. Said he’s had it for a while but never mentioned it to his doctor because he didn’t think it was important. I wrote that down.

MESI results showed right TBI of 0.62. Left TBI 0.81. ABI both sides over 1.0 — looks normal but the platform briefed me that’s expected in diabetic patients. Right TBI is the concerning one. I flagged it per work order escalation protocol and called Dr. M.W.’s office at 10:08. Dr. M.W.’s office called back at 10:34 and confirmed receipt.

Inspected both feet. Right foot: pallor on the bottom, thickened nails, onychomycosis on the big toe, callus on the heel. No open wounds or ulcers. Left foot: looks okay, nails also a bit thickened but no color or temperature issues. Took photos of both feet, uploaded.

Set up CardioSet and walked C.T. and his wife through the measurement and take-home protocol. Wife took over immediately and did it herself on the second try with no help from me. She wrote down the protocol on a notepad herself without me asking. Baseline impedance: 31.4 ohms recorded at 10:28.

Applied Dexcom G7 sensor to right upper arm at 10:52. Set up the share feature with his wife’s phone. She was very happy about that. First reading came through at 12:53 showing 147.

Overall impression: C.T. is cooperative and calm. His wife is exceptional — organized, engaged, asking the right questions. The claudication symptom and the right foot findings are the big clinical story from today. C.T. had no idea any of this was happening. The MESI test found something real.

Engagement score: 5/5 (wife), 4/5 (C.T.). Encounter concluded at 11:38.

PREVENT™ │ CAREVALA, LLC │ SCRIBED CLINICAL NOTE

Patient: C.T. │ PCT-20251001-CT71

To: Dr. M.W. │ Review & Co-Signature Required

Report ID: SCR-20251001-CT71

Generated: October 1, 2025 │ Scribed 13:10

Priority: HIGH — Abnormal Findings Documented

Status: PENDING PHYSICIAN CO-SIGNATURE

Scribed By: PREVENT™ Medical Scribe Service │ Source: PCS Field Notes PCS-20251001-CT71-TR │ Condensed October 1, 2025 at 13:10

ENCOUNTER NOTE

Patient: C.T. │ Age 71 │ Male │ Miami, Florida

Date of Service: October 1, 2025

Encounter Type: PREVENT™ Enrollment Encounter

Clinician of Record: T.R., Patient Care Specialist, PREVENT™ Certified │ Supervising Physician: Dr. M.W.

SUBJECTIVE

Patient is a 71-year-old male with Type 2 Diabetes Mellitus, peripheral neuropathy, hypertension, and CKD Stage 2, presenting for PREVENT™ enrollment encounter. Patient ambulates independently without assistive device. Reports right lower extremity cramping with ambulation beyond approximately two blocks, relieving with rest, consistent with intermittent claudication. Patient reports this symptom has been present for an extended but unspecified duration and was not previously disclosed to his physician, attributing it to normal aging. No chest pain, shortness of breath, or syncopal episodes reported. Wife present and actively manages patient’s medications and household care. Medication adherence confirmed via weekly pill organizer.

OBJECTIVE

General: Alert, oriented, cooperative. Gait slow and steady. No acute distress.

Lower Extremity Vascular Examination: Right foot with pallor on plantar surface. Skin temperature asymmetry — right foot cooler than left on palpation. Absent hair distribution on right great toe, dorsal right foot, and right lower leg below mid-calf. Nails thickened bilaterally; onychomycosis pattern noted on right great toe. Plantar callus present on right heel. No open wounds or ulcerations at time of examination.

Device Measurements: MESI mTABLET: ABI right 1.09, left 1.08 (non-diagnostic due to medial arterial calcification). TBI right 0.62, left 0.81. TBI right below diagnostic threshold of 0.70; PAD confirmed right lower extremity. Digital waveform right: monophasic. VitalScan: Normal sinus rhythm, rate 64 bpm, QTc 441 ms. HRV: SDNN 22 ms, RMSSD 11 ms — both below age-matched reference ranges, consistent with cardiac autonomic neuropathy. CardioSet baseline: 31.4 Ω. Dexcom G7 deployed; first reading 147 mg/dL.

ASSESSMENT

Peripheral arterial disease, right lower extremity — newly identified. TBI 0.62, monophasic digital waveform, classic intermittent claudication, ischemic skin changes. Not previously documented.
Cardiac autonomic neuropathy — newly identified. SDNN 22 ms and RMSSD 11 ms below age-matched reference ranges. Systemic autonomic neuropathy pattern.
Type 2 Diabetes Mellitus, suboptimally controlled. HbA1c 7.8%, CGM time-in-range 54%.
Atherogenic dyslipidemia. LDL 118 mg/dL above PAD target; ApoB 112 mg/dL; Lp(a) 62 mg/dL.
Microalbuminuria (UACR 48 mg/g). Early diabetic nephropathy progression marker.
Vitamin D deficiency. 25-OH Vitamin D 18 ng/mL.

PLAN

Vascular surgery referral — right lower extremity PAD evaluation. Priority: within 2 weeks.
Intensify statin therapy — atorvastatin escalation from 20 mg to 40–80 mg per ACC/AHA PAD guidelines.
Review antiplatelet therapy — aspirin 81 mg currently. Evaluate per PAD guideline indications.
Cardiovascular autonomic reflex testing (CART) referral — formal CAN confirmation.
Podiatry referral — high-risk foot preventive care.
Vitamin D supplementation — 2,000–4,000 IU daily per physician discretion.
Continue CGM monitoring — time-in-range target ≥70%. RDN and CDE sessions initiated.
Authorize PREVENT™ biomarker panel for quarterly monitoring cycle.

PHYSICIAN CO-SIGNATURE & ATTESTATION

I have reviewed the above clinical note generated from PREVENT™ PCS field documentation. I attest that the content accurately reflects the clinical encounter, findings, and plan of care for this patient. I authorize transmission of this note to the patient’s EMR via PREVENT™ Direct Messaging.

Physician Name: Dr. M.W.

Title: Supervising Physician, PREVENT™ │ Primary Care Physician

Date: October 2, 2025 Time: 09:14

Electronic Signature: ___ Dr. M.W. ___ [Authenticated via PREVENT™ Physician Portal]

PREVENT™ │ CAREVALA, LLC │ PHYSICIAN CO-SIGNATURE & EMR AUTHORIZATION

Patient: C.T. │ PCT-20251001-CT71

To: EMR Record │ PREVENT™ Platform

Report ID: AUTH-20251002-CT71-MW

Generated: October 2, 2025 │ 09:14:00

Priority: —

Status: CO-SIGNATURE COMPLETE — CLEARED FOR TRANSMISSION

Dr. M.W. reviewed and co-signed Scribed Clinical Note SCR-20251001-CT71 on October 2, 2025 at 09:14 via the PREVENT™ Physician Portal. Co-signature authenticated by two-factor verification. Note is authorized for transmission to C.T.’s EMR via Direct Messaging.

CO-SIGNATURE LOG

Field	Value
Physician	Dr. M.W.
Note Reference	SCR-20251001-CT71
Co-Signature Date / Time	October 2, 2025 │ 09:14:32
Authentication Method	PREVENT™ Physician Portal — Two-Factor Authentication
Attestation Confirmed	Yes — full attestation text accepted
Transmission Authorized	Yes — Direct Message to EMR cleared
PREVENT™ Compliance Log	AUTH-20251002-CT71-MW filed — retained 7 years per HIPAA

WHAT TRANSMITS TO THE EMR

Encounter note — full scribed clinical note including subjective, objective, assessment, and plan.
MESI mTABLET structured results — ABI bilateral, TBI bilateral, waveform interpretation, PAD confirmation flag.
VitalScan structured results — ECG parameters, HRV values, autonomic neuropathy finding.
CardioSet baseline impedance value and monitoring protocol.
Dexcom G7 CGM deployment confirmation and Days 1–7 summary data.
Biomarker lab results — all layers, flagged values highlighted.
Assessment and plan — eight action items with priority and timeframe.

PREVENT™ │ CAREVALA, LLC │ DIRECT MESSAGE TRANSMISSION RECORD

Patient: C.T. │ PCT-20251001-CT71

To: PREVENT™ Platform │ Compliance Log

Report ID: TX-20251002-CT71-MW

Generated: October 2, 2025 │ 09:15:44

Priority: —

Status: TRANSMISSION COMPLETE — DELIVERY CONFIRMED

The following documents were transmitted to Dr. M.W.’s EMR via PREVENT™ Direct Messaging on October 2, 2025 following physician co-signature authorization.

DOCUMENTS TRANSMITTED

Document	Reference ID	Status
Scribed Clinical Note — Encounter October 1, 2025	SCR-20251001-CT71	Delivered
MESI mTABLET ABI/TBI Report	DEV-20251001-CT71-MESI	Delivered
VitalScan Cardiac & Autonomic Report	DEV-20251001-CT71-VS	Delivered
CardioSet Baseline Report	DEV-20251001-CT71-CS	Delivered
Dexcom G7 CGM Deployment & Days 1–7 Summary	DEV-20251001-CT71-CGM	Delivered
Biomarker Lab Results Report	LAB-20251003-CT71	Delivered — October 3, 2025
Physician Alert Summary	ALT-20251001-CT71-MW	Delivered

ℹ CLINICAL NOTICE

All documents transmitted successfully. No delivery failures.

Dr. M.W. acknowledged receipt of Physician Alert (PAD and CAN findings) via PREVENT™ portal on October 2, 2025 at 10:02.

Transmission log retained in PREVENT™ compliance record for 7 years per HIPAA documentation requirements.

PREVENT™ │ CAREVALA, LLC │ PHYSICIAN REPORT

Patient: C.T. │ Age 71 │ Moderate Tier

To: Dr. M.W. │ Clinical Decision & Action Required

Report ID: PHY-20251002-CT71-MW

Generated: October 2, 2025 │ 09:15:00

Priority: HIGH — Two New Diagnoses Identified

Status: PHYSICIAN ACTION REQUIRED

Dr. M.W. — PREVENT™ enrollment assessment for C.T. is complete. Two conditions were identified that are not documented in C.T.’s existing medical record. The following report summarizes findings and recommended actions for your clinical review.

NEW CLINICAL FINDINGS — NOT PREVIOUSLY DOCUMENTED

Finding	Source	Key Result	Clinical Significance
Peripheral Arterial Disease — Right Lower Extremity	MESI mTABLET TBI │ PCS Observation	TBI Right: 0.62. ABI: 1.09 (non-diagnostic). Monophasic digital waveform. Claudication symptoms present and unreported.	PAD confirmed. Patient at elevated risk for non-healing wounds, ulceration, and limb loss without intervention. Vascular surgery evaluation required.
Cardiac Autonomic Neuropathy	VitalScan HRV Analysis	SDNN 22 ms (ref 38–68). RMSSD 11 ms (ref 20–40). Sympathovagal imbalance.	CAN is an independent predictor of cardiovascular mortality in T2DM. Silent myocardial ischemia risk. Formal CART testing recommended.

⚠ HIGH PRIORITY ALERT

C.T. has been experiencing claudication symptoms in his right leg for an extended period and did not report this to any physician — he attributed it to normal aging. PREVENT™ structured assessment surfaced this history. Without PREVENT™, this PAD presentation would remain undetected.

The ABI was 1.09 — normal range. If ABI had been the only measurement, C.T. would have been incorrectly cleared for vascular disease. The difference between ABI 1.09 and TBI 0.62 is the difference between a missed diagnosis and an identified one.

BIOMARKER FLAGS REQUIRING YOUR REVIEW

Biomarker	Result	Flag	Recommended Action
LDL Cholesterol	118 mg/dL	Above PAD target (< 70)	Escalate atorvastatin to 40–80 mg. PAD is Class I indication for high-intensity statin.
ApoB	112 mg/dL	Elevated (target < 80 high-risk)	ApoB confirms significant atherogenic particle burden beyond what LDL indicates alone.
Lp(a)	62 mg/dL	Elevated (> 50 = independent risk)	Not statin-modifiable. Informs overall cardiovascular risk. Consider PCSK9 inhibitor discussion.
HOMA-IR	6.8	Elevated (> 2.5 = IR)	Significant insulin resistance. Relevant to endocrinologist management of T2DM.
hsCRP	4.8 mg/L	High CV risk category (> 3.0)	Elevated systemic inflammation independent of LDL. Statin intensification partially addresses.
UACR	48 mg/g	Microalbuminuria (30–300)	Early diabetic nephropathy progression. ACE inhibitor optimization relevant.
Vitamin D	18 ng/mL	Deficient (< 20 ng/mL)	Supplementation recommended. Worsens insulin resistance and immune function.

RECOMMENDED ACTIONS — PRIORITIZED

Priority	Action	Rationale	Timeframe
1 — Urgent	Vascular surgery referral — right lower extremity	TBI 0.62 confirms PAD. Establish vascular surgical baseline and intervention threshold.	Within 2 weeks
2 — Urgent	Escalate atorvastatin to 40–80 mg	PAD is Class I indication for high-intensity statin. LDL 118 far above PAD target.	This encounter
3 — Urgent	Review antiplatelet therapy for PAD indication	Aspirin 81 mg currently. Evaluate against ACC/AHA PAD guidelines.	This encounter
4 — Moderate	CART referral — formal CAN confirmation	Guides cardiovascular surveillance intensity and cardiology referral decision.	Within 30 days
5 — Moderate	Podiatry referral — preventive foot care	PAD + neuropathy + ischemic skin changes = high ulceration and amputation risk.	Within 30 days
6 — Moderate	Vitamin D supplementation 2,000–4,000 IU daily	18 ng/mL is deficient. Worsens insulin resistance.	This encounter
7 — Moderate	Authorize PREVENT™ biomarker panel for quarterly cycle	Ongoing monitoring of flagged values.	When ready
8 — Review	Tier escalation to Complex — authorization requested	Five of five escalation criteria met.	This review cycle

PREVENT™ preserves full clinical authority with Dr. M.W. at all times. All recommendations are advisory. No clinical action is taken without physician authorization.

PREVENT™ │ CAREVALA, LLC │ RDN SESSION REPORT — M.B., RDN

Patient: C.T. │ PCT-20251001-CT71

To: Dr. M.W. │ Clinical Record

Report ID: CDT-20251008-CT71-MB

Generated: October 8, 2025 │ 14:30:00

Priority: Moderate

Status: SESSION COMPLETE — FILED

PREVENT™ BRIEF PROVIDED TO M.B. PRIOR TO SESSION

PREVENT™ CLINICAL REASONING

▸ CGM Days 1–7 show postprandial glucose excursions exceeding 180 mg/dL concentrated in the 08:00–10:00 window. Time-in-range: 54% (target ≥70%). High-glycemic breakfast pattern suspected.

▸ Confirmed PAD right foot. Sodium management is critical: hypertension + CKD Stage 2 + CardioSet fluid monitoring profile requires strict sodium discipline.

▸ Cultural context: C.T. is from a Cuban-American background. Miami dietary patterns apply. Meal planning must integrate cultural food preferences to achieve sustainable adherence.

▸ Layer 2 lipids: triglycerides 218 mg/dL, HDL 38 mg/dL. Atherogenic dyslipidemia pattern consistent with insulin resistance. Dietary triglyceride reduction within RDN scope.

▸ Wife manages meals and medications and is highly engaged. She should be treated as a co-implementer of all nutrition interventions.

SESSION FINDINGS & INTERVENTIONS — OCTOBER 8, 2025

CGM data reviewed with C.T. and wife. Postprandial excursions traced to consistent breakfast pattern: white rice, cafecito with sugar, pastry. Wife engaged immediately and began suggesting alternatives before M.B. finished explaining.
Low-glycemic breakfast alternatives identified: eggs, non-starchy vegetables, modest whole grain, unsweetened Cuban coffee. Wife wrote down specific examples.
Sodium reduction plan: target < 2,300 mg/day. High-sodium items in Cuban-American diet identified — canned black beans (rinsed alternative provided), processed meats, restaurant mojo sauces.
Meal timing education: three structured meals with consistent spacing to reduce glucose variability. Late-evening eating pattern identified and addressed.
Triglyceride reduction: reduce refined carbohydrates and sweetened beverages.
Hydration review: adequate fluid intake reinforced for CKD Stage 2. Sweetened beverages flagged.
30-day follow-up scheduled: October 22, 2025. CGM data will be reviewed for time-in-range improvement.

Wife’s Engagement Note: Wife is the primary food preparer. She was fully engaged, took written notes, and asked clarifying questions about specific dishes. Her involvement is the strongest predictor of dietary adherence for this patient.

PREVENT™ │ CAREVALA, LLC │ CDE SESSION REPORT — J.T., CDE

Patient: C.T. │ PCT-20251001-CT71

To: Dr. M.W. │ Clinical Record

Report ID: CDT-20251010-CT71-JT

Generated: October 10, 2025 │ 10:15:00

Priority: Moderate

Status: SESSION COMPLETE — FILED

PREVENT™ BRIEF PROVIDED TO J.T. PRIOR TO SESSION

PREVENT™ CLINICAL REASONING

▸ PAD confirmed right foot (TBI 0.62) and autonomic neuropathy confirmed (SDNN 22 ms). Foot care education is the highest-priority CDE task. Neuropathy reduces pain sensation — C.T. may not feel a wound developing until it is already serious.

▸ CGM active and transmitting. Wife has share feature. Focus on CGM data interpretation, trend arrow literacy, and time-in-range understanding.

▸ Autonomic neuropathy confirmed: educate on orthostatic hypotension risk, hypoglycemia unawareness, and exercise precautions specific to PAD and autonomic dysfunction.

▸ Wife is the medication manager and highest-value care asset. All education should empower both C.T. and his wife equally.

SESSION FINDINGS & INTERVENTIONS — OCTOBER 10, 2025

Foot inspection protocol taught and demonstrated. C.T. and wife both demonstrated correct technique. Daily self-inspection documented as required care plan element.
PAD explained in accessible terms. C.T. now understands that the cramping in his right leg is a circulation problem, not normal aging. This was visibly important information to him.
CGM literacy: trend arrows explained using C.T.’s own Dexcom G7 data. He can now identify rising, falling, stable, and rapid-change patterns. Wife confirmed she understands alert notifications.
Hypoglycemia recognition and response: 15-15 rule reviewed. Emergency contact protocol established.
Autonomic neuropathy implications: orthostatic hypotension risk explained. C.T. instructed to rise slowly from seated or lying position.
Exercise guidance: low-impact walking appropriate but limited by right leg claudication. Seated and pool-based alternatives discussed pending vascular surgery evaluation.
Barefoot ambulation prohibited. C.T. and wife both confirmed understanding. Wife stated she will purchase indoor diabetic slippers this week.
Follow-up scheduled: October 24, 2025.

Clinical Note for Dr. M.W.: C.T. confirmed the claudication symptom has been present for what he estimates to be “a couple of years.” He expressed relief that someone finally identified it as a real problem. Wife asked whether this could lead to amputation. J.T. deferred the clinical prognosis discussion to Dr. M.W. and documented the question for the physician’s awareness.

PREVENT™ │ CAREVALA, LLC │ PHARMACY RECONCILIATION REPORT — D.L.

Patient: C.T. │ PCT-20251001-CT71

To: Dr. M.W. │ Clinical Record

Report ID: PHR-20251006-CT71-DL

Generated: October 6, 2025 │ 09:00:00

Priority: Moderate — Two Clinical Flags

Status: RECONCILIATION COMPLETE — FLAGS FILED

PREVENT™ BRIEF PROVIDED TO D.L. PRIOR TO RECONCILIATION

PREVENT™ CLINICAL REASONING

▸ QTc 441 ms on VitalScan ECG — within normal limits but approaching upper boundary. Flag any QTc-prolonging medications.

▸ PAD now confirmed (TBI 0.62). Review antiplatelet and statin therapy against current ACC/AHA PAD guideline recommendations.

▸ CKD Stage 2 (eGFR 62): flag any nephrotoxic agents or medications requiring renal dose adjustment.

▸ LDL 118 mg/dL, ApoB 112 mg/dL. Statin intensity is a priority review item.

▸ Wife manages all medications. Confirm she holds a complete and accurate medication list.

MEDICATION RECONCILIATION — CONFIRMED REGIMEN

Medication	Class	Indication	Dose Confirmed	Clinical Flag
Metformin 1,000 mg BID	Biguanide	T2DM	Yes	eGFR 62 — acceptable. Reassess if eGFR declines below 45.
Lisinopril 10 mg daily	ACE Inhibitor	Hypertension / CKD renoprotection	Yes	Appropriate. UACR 48 mg/g (microalbuminuria) — ACE inhibitor correctly indicated. Dose may warrant titration per Dr. M.W.
Atorvastatin 20 mg daily	Statin (moderate-intensity)	Cardiovascular risk reduction	Yes	FLAG: PAD confirmed. ACC/AHA PAD guidelines recommend high-intensity statin (atorvastatin 40–80 mg). Current dose subtherapeutic. LDL 118 mg/dL substantially above PAD target of < 70 mg/dL.
Aspirin 81 mg daily	Antiplatelet	Cardiovascular risk	Yes	FLAG: PAD confirmed. Antiplatelet therapy appropriate. Dr. M.W. to evaluate whether aspirin alone is sufficient or whether clopidogrel or cilostazol should be considered for symptomatic PAD.
Hydrochlorothiazide 12.5 mg daily	Thiazide Diuretic	Hypertension	Yes	Acceptable. Monitor electrolytes — potassium 4.2 mEq/L currently normal. Recheck at 90 days.

QTC REVIEW

No QTc-prolonging agents identified in current regimen. QTc 441 ms is within normal limits. D.L. recommends this flag be carried forward in the medication profile so any future additions can be screened against QTc risk.

SUMMARY FLAGS FOR DR. M.W.

● MODERATE ALERT

FLAG 1 — STATIN INTENSITY: Atorvastatin 20 mg is moderate-intensity. PAD confirmation creates a Class I indication for high-intensity statin per ACC/AHA PAD Guidelines. LDL 118 mg/dL is substantially above the PAD target of < 70 mg/dL. Recommend escalation to atorvastatin 40–80 mg.

FLAG 2 — ANTIPLATELET REVIEW: Aspirin 81 mg is appropriate for cardiovascular risk. With symptomatic PAD now confirmed (claudication present), evaluate whether single antiplatelet is sufficient or whether dual therapy or cilostazol for claudication management is indicated.

PREVENT™ │ CAREVALA, LLC │ MONTH-END PHYSICIAN SUMMARY — OCTOBER 2025

Patient: C.T. │ Age 71 │ Moderate Tier

To: Dr. M.W.

Report ID: SUM-20251031-CT71-MW

Generated: October 31, 2025 │ 06:00:00

Priority: Moderate — Tier Escalation Review Pending

Status: MONTH COMPLETE — PHYSICIAN REVIEW REQUIRED

MONTH SUMMARY — WHAT PREVENT™ FOUND AND WHAT HAPPENED

Date	Event	PREVENT™ Action	Outcome
Oct 1	Enrollment. Composite risk score 70. Moderate Tier.	Device & biomarker orders issued. PCS work order sent to T.R.	All devices deployed.
Oct 1	PAD confirmed — TBI right 0.62.	Physician alert issued. Vascular referral recommended.	Dr. M.W. authorized referral Oct 2. Booked Nov 2025.
Oct 1	CAN confirmed — SDNN 22 ms.	Physician alert issued. CART referral recommended.	Dr. M.W. reviewing.
Oct 2	Dr. M.W. co-signed clinical note.	Direct Message transmitted to EMR.	EMR delivery confirmed 09:15:58.
Oct 3	Lab results received — multiple flags.	Flags routed to Physician Report and Direct Message.	Dr. M.W. acknowledged receipt.
Oct 6	Pharmacy reconciliation — two flags filed.	Statin intensity and antiplatelet flags reported.	Dr. M.W. reviewing dose escalation.
Oct 8	RDN session — CGM review, nutrition plan initiated.	PREVENT™ brief with CGM data provided to M.B.	Interventions initiated. Follow-up Oct 22.
Oct 10	CDE session — foot care, CGM literacy, autonomic education.	PREVENT™ brief with PAD and neuropathy priority provided to J.T.	Education complete. Wife fully engaged.
Oct 22	RDN follow-up — CGM time-in-range review.	Updated CGM brief sent to M.B.	TIR improved from 54% to 61%. Positive trend.
Oct 1–31	CardioSet daily monitoring — 30 readings.	No impedance decline ≥8% detected.	No alert triggered. Baseline holding at 31.4 Ω.
Oct 31	Month-end summary generated.	All activity compiled for Dr. M.W.	Tier escalation notice issued.

KEY METRICS — END OF OCTOBER 2025

Metric	Status at Month End
Monitoring Tier	Moderate — Tier Escalation Review Pending
CGM Time-in-Range	61% (enrolled at 54%, target ≥70%) — improving
CardioSet Impedance Trend	Stable. No fluid retention events. Baseline: 31.4 Ω
Vascular Surgery Referral	Authorized. Appointment booked November 2025.
Statin Escalation	Under Dr. M.W. review.
CART Referral	Under Dr. M.W. review.
Podiatry Referral	T.R. coordinating. Target November 2025.
Vitamin D Supplementation	Pending Dr. M.W. prescription.
Care Team Engagement	All four team members completed initial sessions.

WHAT PREVENT™ IDENTIFIED THAT DID NOT EXIST IN THE CHART

Prior to PREVENT™ enrollment, C.T.’s medical record contained his four chronic condition diagnoses and his medication list. Nothing more. PREVENT™ enrollment identified, documented, and transmitted to his EMR:

Peripheral arterial disease — right lower extremity. Never diagnosed. Claudication symptoms present for approximately two years and unreported.
Cardiac autonomic neuropathy. Never documented. Not detectable by standard office ECG.
Atherogenic dyslipidemia pattern: ApoB 112 mg/dL, Lp(a) 62 mg/dL, triglycerides 218 mg/dL — none on prior lab record.
Statin therapy gap: current atorvastatin dose subtherapeutic for newly confirmed PAD indication.
Microalbuminuria (UACR 48 mg/g): early diabetic nephropathy progression marker not in prior record.
Vitamin D deficiency: 18 ng/mL. Not previously measured.
Postprandial glycemic excursion pattern not visible on HbA1c or fingerstick — identified exclusively through CGM.

None of these findings would have emerged from a standard primary care encounter. PREVENT™ was the detection mechanism.

PREVENT™ │ CAREVALA, LLC │ PREVENT™ TIER ESCALATION NOTICE

Patient: C.T. │ PCT-20251001-CT71

To: Dr. M.W. │ Authorization Required

Report ID: ESC-20251031-CT71-MW

Generated: October 31, 2025 │ 06:00:01

Priority: HIGH — Escalation Recommended

Status: PENDING PHYSICIAN AUTHORIZATION

PREVENT™ has completed the 30-day enrollment assessment for C.T. Based on device findings and biomarker results, the platform is recommending escalation from Moderate Tier to Complex Tier. Physician authorization is required to activate the escalation.

ESCALATION CRITERIA MET

Criterion	Threshold	C.T. Finding	Met?
High-risk vascular finding confirmed by device	TBI < 0.70 OR ABI < 0.90	TBI right 0.62 — PAD confirmed	Yes
Autonomic neuropathy confirmed by HRV	SDNN < 30 ms OR RMSSD < 15 ms	SDNN 22 ms, RMSSD 11 ms	Yes
Significant lipid abnormality beyond LDL	ApoB > 100 OR Lp(a) > 50	ApoB 112, Lp(a) 62	Yes
Early renal progression marker	UACR > 30 mg/g	UACR 48 mg/g	Yes
Uncontrolled glycemia with variability	HbA1c > 7.5% AND TIR < 60%	HbA1c 7.8%, TIR 54% at enrollment	Yes

⚠ HIGH PRIORITY ALERT

FIVE OF FIVE ESCALATION CRITERIA MET at 30-day assessment. PREVENT™ recommends immediate escalation to Complex Tier.

Complex Tier activates: enhanced monitoring frequency, expanded care team contact schedule, monthly physician summary with triggered alerts, tightened CardioSet threshold, and Creyos cognitive assessment baseline.

WHAT CHANGES AT COMPLEX TIER

Element	Moderate Tier	Complex Tier
PCS Check-In Frequency	Weekly phone	Weekly phone
CGM Review Frequency	Monthly RDN review	Bi-weekly RDN review
CardioSet Alert Threshold	8% impedance decline	6% impedance decline (tightened)
Biomarker Panel	Quarterly	Quarterly + triggered draws on alert
Care Coordinator Escalation	Standard protocol	Immediate escalation path to Dr. M.W. for any new symptom report
Creyos Cognitive Assessment	Not yet active	Activated — baseline assessment within 30 days of escalation

PHYSICIAN AUTHORIZATION

PHYSICIAN AUTHORIZATION — TIER ESCALATION

I, Dr. M.W., have reviewed the PREVENT™ Tier Escalation Notice ESC-20251031-CT71-MW and the supporting clinical findings for patient C.T. I authorize / do not authorize escalation from Moderate Tier to Complex Tier.

Authorization Decision: ___ Authorize Escalation to Complex Tier ___ Maintain Moderate Tier

Physician Signature: ________________________________ Date: ________________

PREVENT™ │ CAREVALA, LLC │ PLATFORM INTEGRATION & DIRECT MESSAGING NOTE

Patient: PREVENT™ Platform │ Carevala, LLC

To: All Audiences

Report ID: INT-CAREVALA-001

Generated: Current as of October 2025

Priority: —

Status: INFORMATIONAL

PREVENT™ PLATFORM ARCHITECTURE SUMMARY

Layer	Function	Clinical Output
Patient Intake & Enrollment	Ingests ICD-10 codes, calculates composite risk score, assigns monitoring tier with documented reasoning	Enrollment & Tier Assignment Report
Device Recommendation Engine	Analyzes patient profile and selects device protocols. Generates clinical reasoning for each recommendation.	Device & Biomarker Recommendation Order
PCS Coordination	Generates structured work orders for Patient Care Specialists. Provides escalation thresholds and documentation requirements.	PCS Work Order
Device Data Integration	Receives output from MESI mTABLET, VitalScan, CardioSet, Dexcom G7, and all connected devices. Flags abnormal values against clinical thresholds.	Device Reports
Laboratory Integration	Receives biomarker panel results. Flags values against condition-appropriate targets, not population reference ranges alone.	Biomarker Lab Results Report
Medical Scribe Service	Condenses PCS field notes into physician-ready clinical notes per encounter. Routed to physician for co-signature before transmission.	Scribed Clinical Note
Physician Alert System	Generates priority alerts for findings requiring physician clinical decision. Routed via Direct Message.	Physician Alert │ Physician Report
Direct Messaging Transmission	Transmits co-signed documents to physician EMR via HIPAA-compliant Direct Messaging. EMR-agnostic. Delivery confirmed.	Transmission Record
Care Team Coordination	Generates session briefs for RDN, CDE, Pharmacy Tech before each encounter, including platform findings and patient context.	Session Reports
Continuous Monitoring	Monitors CardioSet and CGM data streams. Generates alerts on threshold breach. Tracks trends over time.	Ongoing Alerts │ Month-End Summary
Tier Management	Re-evaluates patient tier at 30-day assessment and on any high-risk finding. Issues escalation notice for physician authorization.	Tier Escalation Notice

PREVENT™ is not a Remote Patient Monitoring (RPM) vendor or a Chronic Care Management (CCM) service. PREVENT™ is a Clinical Status Monitoring platform. The distinction is clinical and operational: PREVENT™ proactively surfaces pathology before it becomes a crisis, coordinates a multi-discipline care team around each patient, and delivers structured clinical findings into the physician’s workflow. Full clinical authority remains with the physician at all times.

C.T. Patient Journey Report │ Active Monitoring Record │ October 2025