AI Scribe for Vascular Surgeons

CLINIC NOTE — VASCULAR SURGERY
Date of Visit: 2026-04-22
Provider: J. Mensah, MD, RPVI

CHIEF COMPLAINT:
"My right calf cramps when I walk to the mailbox."

HPI:
67-year-old male with HTN, DM2 (A1c 7.2), 45-pack-year smoking history (active, 8 cigs/day), and known dyslipidemia, referred by Dr. Singh (PCP) for 6 months of progressive right calf claudication. Onset at 1 block, relieved by 2 minutes of rest, no rest pain or tissue loss. Reports lifestyle limitation — quit walking his dog. No history of MI, stroke, or AAA. No leg ulcers. Denies chest pain, dyspnea, or syncope.

Cardiac risk: documented coronary disease on stress echo 2024, on ASA 81, atorvastatin 80; no known prior PAD intervention.

PMH: HTN, DM2, dyslipidemia, GERD, BPH, OA right knee.
PSH: Lap chole 2018, R inguinal hernia repair 2020.
Allergies: NKDA.
Medications: ASA 81 mg daily, atorvastatin 80 mg daily, lisinopril 20 mg daily, metformin 1 g BID, tamsulosin 0.4 mg daily, omeprazole 20 mg daily.
Family Hx: Father MI age 62; mother stroke age 75. No AAA.
Social: Married, retired electrician, smokes 8 cigs/day (down from 1 ppd), 2 beers/week, no illicits.

ROS:
Cardiac: as above. Pulmonary: occasional SOB on exertion, no orthopnea. GI/GU/MSK/Neuro: as above; no focal neuro deficits, no transient amaurosis, no facial droop or dysarthria.

EXAM:
Vitals: BP 142/86 (right arm), 144/84 (left arm — 2 mmHg gradient), HR 76 regular, RR 14, SpO2 97% RA, BMI 28.4.
General: Well, NAD, smells of tobacco.
Cardiac: RRR, no murmur. No carotid bruits. No abdominal bruit.
Pulmonary: CTA bilaterally.
Abdomen: Soft, no pulsatile mass, no bruit.

Vascular Exam:
- Carotids: 2+ bilaterally, no bruit
- Radial / ulnar: 2+ bilaterally
- Femoral pulses: 2+ bilaterally, no bruit
- Popliteal: right diminished (1+), left 2+
- DP: right absent, left 2+
- PT: right 1+, left 2+
- Capillary refill: right great toe 4 sec, left 2 sec
- Skin: no ulcers, no dependent rubor, no hair loss; toe nails dystrophic bilaterally
- Sensation: protective sensation intact bilaterally on 10 g monofilament

VASCULAR LAB (today):
ABIs:
- Right: 0.62 (brachial 142, ankle 88) — moderate to severe ischemia
- Left: 0.94 (brachial 142, ankle 134) — normal

Segmental pressures right:
- High thigh 138 mmHg — normal
- Low thigh 118 — 20-mmHg drop suggests SFA disease
- Calf 92 — additional drop, popliteal/tibial component
- Ankle 88

Toe pressure right: 38 mmHg (normal > 50). TBI 0.27.
Waveforms: triphasic to common femoral, biphasic at SFA, monophasic at popliteal and below right.

CTA aorta and bilateral lower extremities (2026-04-08, read by Dr. Liu):
- Aorta: normal caliber 2.0 cm infrarenal; no AAA
- Common iliacs: mild calcification, no significant stenosis
- Right SFA: 7-cm focal occlusion mid-vessel, TASC II type B lesion; reconstituted via geniculate collaterals
- Right popliteal: patent
- Right tibial run-off: 2-vessel (PT and peroneal); AT occluded mid-calf
- Left lower extremity: mild calcification, no flow-limiting stenosis

ASSESSMENT:
67-year-old smoker with DM2, dyslipidemia, and CAD presenting with 6 months of right calf intermittent claudication, lifestyle-limiting at 1 block.
1. Right lower extremity peripheral arterial disease, Rutherford class 3, intermittent claudication (I70.211)
2. Right SFA TASC II type B occlusion, suitable for endovascular revascularization
3. Active tobacco use disorder, severe (F17.210) — barrier to durability of any intervention
4. Atherosclerotic cardiovascular disease, on appropriate secondary prevention
5. Type 2 diabetes mellitus, A1c 7.2 — at goal but room to optimize

PLAN:
1. Optimize medical therapy (COMPASS regimen): start rivaroxaban 2.5 mg BID in addition to ASA 81 mg; continue atorvastatin 80 mg with goal LDL < 70 (last LDL 78 — recheck in 8 weeks).
2. Add cilostazol 100 mg BID (no HF on echo 2024); counseled on headache and palpitations side effects.
3. Tobacco cessation: strongly counseled. Prescribed varenicline 0.5 mg daily × 3 days then 1 mg BID; QuitLine referral. Discussed that ongoing smoking will halve the durability of any intervention.
4. Structured supervised exercise program referral — Medicare covers 12 weeks for SET in symptomatic PAD. 30-min walks, treadmill, 3×/week.
5. Diabetes — coordinating with PCP for SGLT2 trial given CV indication.
6. Follow-up: 8 weeks for ABI recheck and decision on endovascular intervention. If lifestyle limitation persists despite 8 weeks of optimal medical therapy + SET, plan right SFA recanalization with balloon angioplasty +/- DCB +/- stent (CPT 37224 or 37226 depending on stent placement).
7. Consent and risk discussion deferred to pre-procedural visit.
8. Patient verbalized understanding. Educational handout on PAD provided. Clinic phone number reviewed for any rest pain, ulcer, or sudden cold/painful limb.

Time spent face-to-face with patient: 35 minutes; > 50% on counseling and coordination of care.
Billing: 99214 with prolonged service add-on if eligible; ABI interpretation 93922 (bilateral); review of CTA 76376.