AI Scribe for Hematologists

SUBJECTIVE:
56-year-old female referred for evaluation of unprovoked left lower extremity DVT diagnosed 2 weeks ago. Patient presented to ED with left leg swelling and pain. Doppler ultrasound showed acute DVT involving left popliteal and femoral veins. Started on rivaroxaban 15mg BID. No prior history of VTE. No recent surgery, travel, or immobilization. Family history significant for mother with PE at age 62. No active bleeding. Denies shortness of breath or chest pain.

OBJECTIVE:
Vitals: BP 128/76, HR 78, RR 16, SpO2 98% RA
General: Well-appearing, no acute distress
Cardiovascular: Regular rate and rhythm, no murmurs
Lungs: Clear to auscultation bilaterally
Left Lower Extremity: Mild residual edema (2cm difference in calf circumference compared to right), no erythema, homans sign negative, pulses intact

LABS (from 2 weeks ago at DVT diagnosis):
- CBC: WBC 7.2, Hgb 13.8, Plt 245,000
- PT/INR: 1.0
- aPTT: 28 seconds
- D-dimer: 3,245 ng/mL (elevated)
- CrCl: 82 mL/min

LABS (today - thrombophilia workup):
- Factor V Leiden: Positive (heterozygous)
- Prothrombin G20210A mutation: Negative
- Protein C activity: 98% (normal)
- Protein S activity: 102% (normal)
- Antithrombin III: 96% (normal)
- Lupus anticoagulant: Negative
- Anticardiolipin antibody: Negative
- Anti-beta-2-glycoprotein I: Negative
- Homocysteine: 8.2 mcmol/L (normal)

IMAGING:
- Lower extremity doppler (today): Partial recanalization of left femoral vein, residual thrombus in popliteal vein, no extension

ASSESSMENT:
1. Unprovoked left lower extremity deep vein thrombosis
   - Currently on rivaroxaban 15mg BID (acute phase dosing)
   - Clinical improvement with partial recanalization
2. Factor V Leiden heterozygous - likely contributing thrombophilia
3. Family history of venous thromboembolism (mother with PE)

PLAN:
1. Continue rivaroxaban 15mg BID for total 21 days (10 more days remaining), then transition to 20mg once daily
2. Extended anticoagulation recommended given:
   - Unprovoked DVT
   - Factor V Leiden heterozygous
   - Positive family history
   - Low bleeding risk (HAS-BLED score: 0)
3. Plan for indefinite anticoagulation unless contraindication develops
4. Discussed risks/benefits of long-term anticoagulation
5. Bleeding precautions reviewed
6. Compression stockings 20-30 mmHg for post-thrombotic syndrome prevention
7. Repeat doppler ultrasound in 3 months to assess for recanalization
8. Avoid estrogen-containing medications
9. Genetic counseling offered for family members
10. Follow-up in 3 months with repeat CBC, CrCl
11. Advised to contact immediately if: severe bleeding, severe headache, chest pain, severe leg swelling
12. Provided anticoagulation wallet card and emergency contact information