mtsamples_top40_gold.json

[
  {
    "note_id": 1357,
    "specialty": "SOAP / Chart / Progress Notes",
    "sample_name": "Leg Pain & Bone Pain",
    "visit_date_assumed": "2025-01-15",
    "transcription": "CHIEF COMPLAINT:,  Leg pain.,HISTORY OF PRESENT ILLNESS:,  This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle.  She has noticed it since she has been on Lipitor.  She has had some night sweats occasionally.  She has had a little bit of fever and nausea.  She has noticed her blood sugars have been low.  She has lost over 30 pounds after exercising doing water aerobics at Genesis in Wichita.  She has noticed her fasting blood sugars have been ranging from 100 to 120.  Blood sugars one and a half hours after meals have been 185.  She is coming in for a diabetic checkup in one month and wants lab prior to that time.  She has been eating more meat recently and has not been on a diet for cholesterol.,CURRENT MEDICATIONS:,  Include Lipitor 80 mg q.d. discontinued today, Vioxx 25 mg q.d., Maxzide 37/25 q.d., Protonix 40 mg q.d., hydroxyzine pamoate 50 mg at h.s., aspirin 81 mg q.d., Glucovance 1.25/250 b.i.d. decreased to one a day today, Monopril 20 mg q.d., estradiol one mg q.d., and glucosamine 1000 mg q.d.,ALLERGIES:,  Cipro, sulfa, Bactrim, and Demerol.,OBJECTIVE:,Vital Signs:  Weight is 248 pounds which is a 12-pound drop from January.  Blood pressure 120/70.  Pulse 68.,General:  This is a well-developed adult female, awake, alert, and in no acute distress.,HEENT:  Oropharynx and HEENT are within normal limits.,Lungs:  Clear.,Heart:  Regular rhythm and rate.,Abdomen:  Soft, nontender, and nondistended without organomegaly.,GU:  Palpation of femurs do not cause pain, rotation of hips do not cause pain, and compression of the hips do not cause pain.,Neurologic:  Deep tendon reflexes are normal.,Extremities:  Pulses in lower extremities are normal.  Straight leg lifts are normal.,ASSESSMENT/PLAN:,1.  Leg pain/bone pain, I am going to check her CMP.  I think this possibly is a side effect from Lipitor.  We will stop Lipitor, have her follow up in one month which she has already got planned for diabetes appointment and check symptoms at that time.  Certainly if her pain improves might consider something like Crestor, which is more water soluble, which may cause less adverse effects.  We will check her comprehensive metabolic panel to make sure the alkaline phosphatase is okay, may need an x-ray of back, hip, and legs at that time if symptoms are not gone.,2.  Hypercholesterolemia, this is somewhat bothersome as she is a diabetic.  Did discuss with her that we need to stick to the diet especially after going off of Lipitor.  We will see how she does with her bone pain/leg pain off of Lipitor.  If she has improvement may consider Crestor in one month.  I am going to check her lipid panel and a CMP.  Apparently, she is going to get this at a different site, Mapleridge in Wichita.,3.  Type II diabetes.  We will decrease her Glucovance because she is having frequent low blood sugars.  Her previous hemoglobin A1c was 5.6 so we will see if this improves her symptoms.  I am also going to check a hemoglobin A1c at Mapleridge in Wichita and have a followup here in one month for that diabetes appointment.",
    "follow_up_items": [
      {
        "action": "Annual Physical",
        "action_verbatim": "diabetic checkup",
        "period_text": "in one month",
        "period_date": "2025-02-15",
        "action_char_start": 678,
        "action_char_end": 694,
        "time_char_start": 695,
        "time_char_end": 707,
        "in_closed_set": true,
        "coverage_note": "in_set"
      },
      {
        "action": "X-Ray",
        "action_verbatim": "x-ray of back, hip, and legs",
        "period_text": "at that time",
        "period_date": null,
        "action_char_start": 2343,
        "action_char_end": 2371,
        "time_char_start": 2083,
        "time_char_end": 2095,
        "in_closed_set": true,
        "coverage_note": "conditional"
      },
      {
        "action": null,
        "action_verbatim": "follow up",
        "period_text": "in one month",
        "period_date": "2025-02-15",
        "action_char_start": 1982,
        "action_char_end": 1991,
        "time_char_start": 695,
        "time_char_end": 707,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      },
      {
        "action": null,
        "action_verbatim": "Crestor",
        "period_text": "in one month",
        "period_date": "2025-02-15",
        "action_char_start": 2159,
        "action_char_end": 2166,
        "time_char_start": 695,
        "time_char_end": 707,
        "in_closed_set": false,
        "coverage_note": "med_change"
      }
    ]
  },
  {
    "note_id": 1447,
    "specialty": "SOAP / Chart / Progress Notes",
    "sample_name": "Asperger Disorder",
    "visit_date_assumed": "2025-01-15",
    "transcription": "SUBJECTIVE:  ,School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom.  He appears confused and depressed at times.  Mother also indicates that preservative questioning had come down, but he started collecting old little toys that he did in the past.  He will attend social skills program in the summer.  ABCD indicated to me that they have identified two psychologists to refer him to for functional behavioral analysis.  There is lessening of tremoring in both hands since discontinuation of Zoloft.  He is now currently taking Abilify at 7.5 mg.,OBJECTIVE: , He came in less perseverative questioning, asked appropriate question about whether I talked to ABCD or not, greeted me with Japanese word to say hello, seemed less.,I also note that his tremors were less from the last time.,ASSESSMENT: , 299.8 Asperger disorder, 300.03 obsessive compulsive disorder.,PLAN:,  Decrease Abilify from 7.5 mg to 5 mg tablet one a day, no refills needed.  I am introducing slow Luvox 25 mg tablet one-half a.m. for OCD symptoms, if no side effects in one week we will to tablet one up to therapeutic level.,I also will call ABCD regarding the referral to psychologists for functional behavioral analysis.  Parents will call me in two weeks.  I will see him for medication review in four weeks.  Mother signed informed consent.  I reviewed side effects to observe including behavioral activation.,Abilify has been helpful in decreasing high emotional arousal.  Combination of medication and behavioral intervention is recommended.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "Decrease Abilify from 7.5 mg to 5 mg",
        "period_text": null,
        "period_date": null,
        "action_char_start": 994,
        "action_char_end": 1030,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "Luvox 25 mg tablet one-half",
        "period_text": "in one week",
        "period_date": "2025-01-22",
        "action_char_start": 1091,
        "action_char_end": 1118,
        "time_char_start": 1161,
        "time_char_end": 1172,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "Parents will call me",
        "period_text": "in two weeks",
        "period_date": "2025-01-29",
        "action_char_start": 1319,
        "action_char_end": 1339,
        "time_char_start": 1340,
        "time_char_end": 1352,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      },
      {
        "action": null,
        "action_verbatim": "medication review",
        "period_text": "in four weeks",
        "period_date": "2025-02-12",
        "action_char_start": 1374,
        "action_char_end": 1391,
        "time_char_start": 1392,
        "time_char_end": 1405,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      },
      {
        "action": null,
        "action_verbatim": "referral to psychologists",
        "period_text": null,
        "period_date": null,
        "action_char_start": 1256,
        "action_char_end": 1281,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "referral"
      }
    ]
  },
  {
    "note_id": 2253,
    "specialty": "Orthopedic",
    "sample_name": "CT Neck - 1",
    "visit_date_assumed": "2025-01-15",
    "transcription": "FINDINGS:,There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm (mediolateral x AP x craniocaudal) in size. There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds. There is marked enlargement of the bilateral aryepiglottic folds (left greater than right). There is thickening of the glossoepiglottic fold. There is an infiltrative mass like lesion extending into the pre-epiglottic space.,There is no demonstrated effacement of the piriform sinuses. The mass obliterates the right vallecula. The paraglottic spaces are normal. The true and false cords appear normal. Normal thyroid, cricoid and arytenoid cartilages.,There is lobulated thickening of the right side of the tongue base, for which invasion of the tongue cannot be excluded. A MRI examination would be of benefit for further evaluation of this finding.,There is a 14 x 5 x 12 mm node involving the left submental region (Level I).,There is borderline enlargement of the bilateral jugulodigastric nodes (Level II). The left jugulodigastric node,measures 14 x 11 x 8 mm while the right jugulodigastric node measures 15 x 12 x 8 mm.,There is an enlarged second left high deep cervical node measuring 19 x 14 x 15 mm also consistent with a left Level II node, with a probable necrotic center.,There is an enlarged second right high deep cervical node measuring 12 x 10 x 10 mm but no demonstrated central necrosis.,There is an enlarged left mid level deep cervical node measuring 9 x 16 x 6 mm, located inferior to the hyoid bone but cephalad to the cricoid consistent with a Level III node.,There are two enlarged matted nodes involving the right mid level deep cervical chain consistent with a right Level III nodal disease, producing a conglomerate nodal mass measuring approximately 26 x 12 x 10 mm.,There is a left low level deep cervical node lying along the inferior edge of the cricoid cartilage measuring approximately 18 x 11 x 14 mm consistent with left Level IV nodal disease.,There is no demonstrated pretracheal, prelaryngeal or superior mediastinal nodes. There is no demonstrated retropharyngeal adenopathy.,There is thickening of the adenoidal pad without a mass lesion of the nasopharynx. The torus tubarius and fossa of Rosenmuller appear normal.,IMPRESSION:,Epiglottic mass lesion with probable invasion of the glossoepiglottic fold and pre-epiglottic space with invasion of the bilateral aryepiglottic folds.,Lobulated tongue base for which tongue invasion cannot be excluded. An MRI may be of benefit for further assessment of this finding.,Borderline enlargement of a submental node suggesting Level I adenopathy.,Bilateral deep cervical nodal disease involving bilateral Level II, Level III and left Level IV.",
    "follow_up_items": [
      {
        "action": "MRI",
        "action_verbatim": "MRI examination",
        "period_text": null,
        "period_date": null,
        "action_char_start": 844,
        "action_char_end": 859,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": true,
        "coverage_note": "no_time"
      },
      {
        "action": "MRI",
        "action_verbatim": "MRI",
        "period_text": null,
        "period_date": null,
        "action_char_start": 844,
        "action_char_end": 847,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": true,
        "coverage_note": "no_time"
      }
    ]
  },
  {
    "note_id": 2277,
    "specialty": "Orthopedic",
    "sample_name": "Cartilage Loose Body Removal",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PREOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,POSTOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,PROCEDURES:,  Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,ANESTHESIA: , General.,TOURNIQUET TIME:  ,Thirty-seven minutes.,MEDICATIONS: , The patient also received 30 mL of 0.5% Marcaine local anesthetic at the end of the case.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,INTRAOPERATIVE FINDINGS: , The patient had a loose body that was found in the suprapatellar pouch upon entry of the camera.  This loose body was then subsequently removed.  It measured 24 x 14 mm.  This was actually the OCD lesion seen on the MRI that had come from the weightbearing surface of just the lateral posterior aspect of the medial femoral condyle,HISTORY AND PHYSICAL: , The patient is 13-year-old male with persistent left knee pain.  He was initially seen at Sierra Pacific Orthopedic Group where an MRI demonstrated unstable OCD lesion of the left knee.  The patient presented here for a second opinion.  Surgery was recommended grossly due to the instability of the fragment.  Risks and benefits of surgery were discussed.  The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure to relieve pain or restore the articular cartilage, possible need for other surgical procedures, and possible early arthritis.  All questions were answered and parents agreed to the above plan.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The extremity was then prepped and draped in standard surgical fashion.  The standard portals were marked on the skin.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  The portal incisions were then made by an #11 blade.  Camera was inserted into the lateral joint line.  There was a noted large cartilage loose body in the suprapatellar pouch.  This was subsequently removed with extension of the anterolateral portal.  Visualization of the rest of the knee revealed significant synovitis.  The patient had a large cartilage defect in the posterolateral aspect of the medial femoral condyle.  The remainder of the knee demonstrated no other significant cartilage lesions, loose bodies, plica or meniscal pathology.  ACL was also visualized to be intact in the intracondylar notch.,Attention was then turned back to the large defect.  The loose cartilage was debrided using a shaver.  Microfracture technique was then performed to 4 mm depth at 2 to 3 mm distances.  Tourniquet was released at the end of the case to ensure that there was fat and bleeding at the microfracture sites.  All instruments were then removed.  The portals were closed using #4-0 Monocryl.  A total of 30 mL of 0.5% Marcaine was injected into the knee.  Wounds were then cleaned and dried, and dressed in Steri-Strips, Xeroform, 4 x 4s, and bias.  The patient was then placed in a knee immobilizer.  The patient tolerated the procedure well.  The tourniquet was released at 37 minutes.  He was taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The loose cartilage fragment was given to the family.  The intraoperative findings were relayed with intraoperative photos.  There was a large deficit in the weightbearing portion of medial femoral condyle.  His prognosis is guarded given the fact of the fragile lesion and location, but in advantages of his age and his rehab potential down the road, if the patient still has symptoms, he may be a candidate for osteochondral autograft, a procedure which is not performed at Children's or possible cartilaginous transplant.  All questions were answered.  The patient will follow up in 10 days, may wet the wound in 5 days.",
    "follow_up_items": [
      {
        "action": "Orthopedic Consult",
        "action_verbatim": "follow up",
        "period_text": "in 10 days",
        "period_date": "2025-01-25",
        "action_char_start": 4049,
        "action_char_end": 4058,
        "time_char_start": 4059,
        "time_char_end": 4069,
        "in_closed_set": true,
        "coverage_note": "in_set"
      },
      {
        "action": null,
        "action_verbatim": "may wet the wound",
        "period_text": "in 5 days",
        "period_date": "2025-01-20",
        "action_char_start": 4071,
        "action_char_end": 4088,
        "time_char_start": 4089,
        "time_char_end": 4098,
        "in_closed_set": false,
        "coverage_note": "self_care"
      }
    ]
  },
  {
    "note_id": 1036,
    "specialty": "Surgery",
    "sample_name": "Cineangiography - 1",
    "visit_date_assumed": "2025-01-15",
    "transcription": "REASON FOR CATHETERIZATION:,  ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Left ventriculogram.,4.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.,PROCEDURE: , After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac cath suite.  Right groin was prepped in usual sterile fashion.  Right common femoral artery was cannulated with the modified Seldinger technique.  A 6-French sheath was introduced.  Next, Judkins right catheter was used to engage the right coronary artery and cineangiography was recorded in multiple views.  Next, an EBU 3.5 guide was used to engage the left coronary system.  Cineangiography was recorded in several views and it was noted to have a 99% proximal left circumflex stenosis.  Angiomax bolus and drip were started after checking an ACT, which was 180, and an Universal wire was advanced through the left circumflex beyond the lesion.  Next, a 3.0 x 12 mm balloon was used to pre-dilate the lesion.  Next a 3.5 x 12 mm Vision bare-metal stent was advanced to the area of stenosis and deployed at 12 atmospheres.  There was noted to be a plaque shift proximally at the edge of the stent.  Therefore, a 3.5 x 8 mm Vision bare-metal stent was advanced to cover the proximal margin of the first stent and deployed at 12 atmospheres.  Next, a 3.75 x 13 mm noncompliant balloon was advanced into the margin of the stent and two inflations at 20 atmospheres were done for 20 seconds.  Final images showed excellent results with initial 99% stenosis reduced to 0%.  The patient continues to have residual stenosis in the mid to distal in the OM branch.  At this point, wire was removed.  Final images confirmed initial stent results, no evidence of dissection, perforation, or complications.,Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressure was measured.  LV gram was done in both the LAO and RAO projections and a pullback gradient across the aortic valve was done and recorded.  Finally, all guides were removed.  Right femoral artery access site was imaged and Angio-Seal deployed to attain excellent hemostasis.  The patient tolerated the procedure very well without complications.,DIAGNOSTIC FINDINGS,1.  Left main:  Left main is a large-caliber vessel bifurcating in LAD and left circumflex with no significant disease.,2.  The LAD:  LAD is a large-caliber vessel, wraps around the apex, gives off multiple septal perforators, three small-to-medium caliber diagonal branches without any significant disease.,3.  Left circumflex:  Left circumflex is a large-caliber vessel, gives off a large distal PDA branch, has a 99% proximal lesion, 50% mid vessel lesion, and a 50% lesion in the OM, which is a distal branch.,4.  Right coronary artery:  Right coronary artery is a moderate-caliber vessel, dominant, bifurcates into PDA and PLV branches, has only mild disease.  Otherwise, no significant stenosis noted.,5.  LV:  The LVEF 50%.  Inferolateral wall hypokinesis.  No significant mitral regurgitation.  No gradient across the aortic valve on pullback.,ASSESSMENT AND PLAN: , ST-elevation myocardial infarction with a 99% stenosis of the proximal portion of the left circumflex treated with a 3.5 x 12 mm Vision bare-metal stent and a 3.5 x 8 mm Vision bare-metal stent.  Excellent results, 0% residual stenosis.  The patient continues to have some residual 50% stenosis in the left circumflex system, some mild disease throughout the other vessels.  Therefore, we will aggressively treat this patient medically with close followup as an outpatient.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "close followup as an outpatient",
        "period_text": null,
        "period_date": null,
        "action_char_start": 3754,
        "action_char_end": 3785,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "vague"
      }
    ]
  },
  {
    "note_id": 2040,
    "specialty": "Orthopedic",
    "sample_name": "Tailor Bunionectomy with Screw Fixation",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,PROCEDURES PERFORMED:  ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:,  Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:,  A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw.  A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position.  At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis.  Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site.  The right foot was then scrubbed, prepped, and draped in the usual aseptic manner.  An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg.  Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made.  The incision was carried deep utilizing both sharp and blunt dissections.  All major neurovascular structures were avoided.  At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified.  This was then incised fully exposing the tendon and the abductor hallucis muscle.  This was then resected from his osseous attachments and a small tenotomy was performed.  At this time, a small lateral capsulotomy was also performed.  Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision.  The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field.  A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye.  The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position.  The dorsal arm was made longer than the plantar arm to accommodate for fixation.  At this time, the capital fragment was resected and shifted laterally into a more corrected position.  At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation.  Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site.  Compression was noted to be excellent.  All guide wires and 0.045-inch K-wires were then removed.  Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field.  The wound was then once again flushed with copious amounts of sterile normal saline.  At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated.  At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon.  At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension.  Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal.  Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field.  Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head.  The head was then shifted medially into a more corrected position.  A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site.  This was noted to be in correct position and compression was noted to be excellent.  Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field.  The wound was once again flushed with copious amounts of sterile normal saline.  The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon.  At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site.  The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion.  The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot.  The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot.  After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A.  The patient is to be nonweightbearing to the right foot.  The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these.  The patient tolerated the procedure and anesthesia well.  Dr. A was present throughout the entire case.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "follow up with Dr. A",
        "period_text": null,
        "period_date": null,
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        "in_closed_set": false,
        "coverage_note": "vague"
      }
    ]
  },
  {
    "note_id": 2095,
    "specialty": "Orthopedic",
    "sample_name": "Ortho - Letter - 1",
    "visit_date_assumed": "2025-01-15",
    "transcription": "XYZ, D.C.,Re:  ABC,Dear Dr. XYZ:,I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation.  He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side.  The patient sustained impact injuries to his neck and lower back.  There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures.  He was taken to Hospital, x-rays were taken, apparently which were negative and he was released.,At the present time, he complains of neck and lower back pain radiating into his right arm and right leg with weakness, numbness, paraesthesia, and tingling in his right arm and right leg.  He has had no difficulty with bowel or bladder function.  He does experience intermittent headaches associated with his neck pain with no other associated symptoms.,PAST HEALTH:,  He was injured in a prior motor vehicle accident on MM/DD/YYYY.  At the time of his most recent injuries, he was completely symptom free and under no active therapy.  There is no history of hypertension, diabetes, heart disease, neurological disorders, ulcers or tuberculosis.,SOCIAL HISTORY: , He denies tobacco or alcohol consumption.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:  ,None.,FAMILY HISTORY: , Otherwise noncontributory.,FUNCTIONAL INQUIRY: , Otherwise noncontributory.,REVIEW OF DIAGNOSTIC STUDIES:,  Includes an MRI scan of the cervical spine dated MM/DD/YYYY which showed evidence for disc bulging at the C6-C7 level.  MRI scan of the lumbar spine on MM/DD/YYYY, showed evidence of a disc herniation at the L1-L2 level as well as a disc protrusion at the L2-L3 level with disc herniations at the L3-L4 and L4-L5 level and disc protrusion at the L5-S1 level.,PHYSICAL EXAMINATION: , Reveals an alert and oriented male with normal language function.  Vital Signs:  Blood pressure was 105/68 in the left arm sitting.  Heart rate was 70 and regular.  Height was 5 feet 8 inches.  Weight was 182 pounds.  Cranial nerve evaluation was unremarkable.  Pupils were equal and reactive.  Funduscopic evaluation was clear.  There was no evidence for nystagmus.  There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree, with tenderness and spasm in the paraspinal musculature.  Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left.  Motor strength was 5/5 on the MRC scale.  Reflexes were 2+ symmetrical and active.  No pathological responses were noted.  Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity.  Cerebellar function was normal.  There was normal station and gait.  Chest and cardiovascular evaluations were unremarkable.  Heart sounds were normal.  There were no extra sounds or murmurs.  Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature.,CLINICAL IMPRESSION: , Reveals a 19-year-old male suffering from a posttraumatic cervical and lumbar radiculopathy, secondary to traumatic injuries sustained in a motor vehicle accident on MM/DD/YYYY.  In view of the persistent radicular complaints associated with the weakness, numbness, paraesthesia, and tingling as well as the objective sensory loss noted on today's evaluation as well as the non-specific nature of the radiculopathy, I have scheduled him for an EMG study on his right upper and right lower extremity in two week's time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms.  Palpable trigger points were noted on today's evaluation.  He is suffering from ongoing myofascitis.  His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks' time.  I have encouraged him to continue with his ongoing treatment program under your care and supervision.  I will be following him in two weeks' time.  Once again, thank you kindly for allowing me to participate in this patient's care and management.,Yours sincerely,,",
    "follow_up_items": [
      {
        "action": "EMG",
        "action_verbatim": "EMG study",
        "period_text": "in two week's time",
        "period_date": null,
        "action_char_start": 3483,
        "action_char_end": 3492,
        "time_char_start": 3538,
        "time_char_end": 3556,
        "in_closed_set": true,
        "coverage_note": "in_set"
      },
      {
        "action": "Joint Injection",
        "action_verbatim": "trigger point injections",
        "period_text": "in two weeks' time",
        "period_date": "2025-01-29",
        "action_char_start": 3828,
        "action_char_end": 3852,
        "time_char_start": 3897,
        "time_char_end": 3915,
        "in_closed_set": true,
        "coverage_note": "in_set"
      },
      {
        "action": null,
        "action_verbatim": "following him",
        "period_text": "in two weeks' time",
        "period_date": "2025-01-29",
        "action_char_start": 4031,
        "action_char_end": 4044,
        "time_char_start": 3897,
        "time_char_end": 3915,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      }
    ]
  },
  {
    "note_id": 2236,
    "specialty": "Orthopedic",
    "sample_name": "Elbow Manipulation",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PREOPERATIVE DIAGNOSIS:,  Left elbow with retained hardware.,POSTOPERATIVE DIAGNOSIS: , Left elbow with retained hardware.,PROCEDURE: , ,1.  Left elbow manipulation.,2.  Hardware removal of left elbow.,ANESTHESIA:  ,Surgery was performed under general anesthesia.,COMPLICATIONS:,  There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,INTRAOPERATIVE FINDING: , Preoperatively, the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees.  We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees.,LOCAL ANESTHETIC:  ,10 mL of 0.25% Marcaine.,HISTORY AND PHYSICAL: , The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007.  The patient underwent open reduction and internal fixation of his left elbow fracture dislocation.  The patient also sustained a nondisplaced right glenoid neck fracture.  The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint.  The patient is neurologically intact distally.  Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware.  Risks and benefits of the surgery were discussed.  The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness.  All questions were answered and the parents agreed to the above plan.,PROCEDURE:  ,The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in a standard surgical fashion.  Using fluoroscopy, the patient's K-wire was located.  An incision was made over his previous scar.  A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles.  The K-wires were easily palpable.  A small incision was made into the triceps, which allowed for visualization of the two pins, which were removed without incident.  The wound was then irrigated.  The triceps split was now closed using #2-0 Vicryl.  The subcutaneous tissue was also closed using #2-0 Vicryl and the skin with #4-0 Monocryl.  The wound was clean and dry and dressed with Steri-Strips, Xeroform, and 4 x 4s, as well as bias.  A total of 10 mL of 0.25% Marcaine was injected into the incision, as well as the joint line.  At the beginning of the case, prior to removal of the hardware, the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees, flexion to 130 degrees and pronation supination to about 40 degrees.,DIAGNOSTIC IMPRESSION:  ,The postoperative films demonstrated no fracture, no retained hardware.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will restart physical therapy and Dynasplint in 3 days.  The patient is to follow up in 1 week's time for a wound check.  The patient was given Tylenol No.  3 for pain.",
    "follow_up_items": [
      {
        "action": "Physical Therapy",
        "action_verbatim": "physical therapy and Dynasplint",
        "period_text": "in 3 days",
        "period_date": "2025-01-18",
        "action_char_start": 3162,
        "action_char_end": 3193,
        "time_char_start": 3194,
        "time_char_end": 3203,
        "in_closed_set": true,
        "coverage_note": "in_set"
      },
      {
        "action": "Orthopedic Consult",
        "action_verbatim": "follow up",
        "period_text": "in 1 week's time",
        "period_date": null,
        "action_char_start": 3224,
        "action_char_end": 3233,
        "time_char_start": 3234,
        "time_char_end": 3250,
        "in_closed_set": true,
        "coverage_note": "in_set"
      }
    ]
  },
  {
    "note_id": 2451,
    "specialty": "Office Notes",
    "sample_name": "Premature retina and vitreous",
    "visit_date_assumed": "2025-01-15",
    "transcription": "OCULAR FINDINGS: , Anterior chamber space:  Cornea, iris, lens, and pupils all unremarkable on gross examination in each eye.,Ocular adnexal spaces appear very good in each eye.,Cyclomydril x2 was used to dilate the pupil in each eye.,Medial spaces are clear and the periphery is still hazy in each eye.,Ocular disc space, normal size and shape with a pink color with clear margin in each eye.,Macular spaces are normal in appearance for the age in each eye.,Posterior pole.  No dilated blood vessels seen in each eye.,Periphery:  The peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye.,IMPRESSION:  ,Premature retina and vitreous, each eye.,PLAN:  ,Recheck in two weeks.,",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "Recheck",
        "period_text": "in two weeks",
        "period_date": "2025-01-29",
        "action_char_start": 707,
        "action_char_end": 714,
        "time_char_start": 715,
        "time_char_end": 727,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      }
    ]
  },
  {
    "note_id": 2249,
    "specialty": "Orthopedic",
    "sample_name": "Delayed ORIF",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PREOPERATIVE DIAGNOSES:,1.  Right ankle trimalleolar fracture.,2.  Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,OPERATIVE PROCEDURE:  ,Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment, as well as medial malleolar fragment.,POSTOPERATIVE DIAGNOSES:,1.  Right ankle trimalleolar fracture.,2.  Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,TOURNIQUET TIME: , 80 minutes.,HISTORY: , This 50-year-old gentleman was from the area and riding his motorcycle in Kentucky.,The patient lost control of his motorcycle when he was traveling approximately 40 mile per hour.  He was on a curve and lost control.  He is unsure what exactly happened, but he thinks his right ankle was pinned underneath the motorcycle while he was sliding.  There were no other injuries.  He was treated in Kentucky.  A close reduction was performed and splint applied.  Orthopedic surgeon called myself with regards to this patient's fracture management and suggested a CT scan.  The patient returned to Ohio and his friend drove him all the way from Kentucky to Northwest Ohio overnight.  The patient showed up in the emergency department where a CT scan was asked to be performed.  This was performed and reviewed.  The patient, however, had significant amount of soft tissue swelling and therefore he was asked to follow up in 2 days.  At this time, he still had significant swelling, but because of the amount of swelling that he had particularly with the long car ride for many hours with his leg dependent, it was felt to be best to wait.,Indeed after 7 days, the patient started to develop fracture blisters on the posterior medial aspect of his ankle with large blisters measuring approximately 2 to 3 inches.  The patient was x-rayed in the office.  He had lost some of his reduction.  Therefore, he was re-reduced at approximately 7 days and then each time the patient had examination of tissues, he was re-reduced just to keep the pressure off the skin.,An x-ray showed the distal fibular fracture starting at the mortise region laterally.  It appeared as an abduction type injury with minimal rotation.  This was comminuted, fragmented, and impacted.,The medial malleolus fracture was an avulsion type.  The syndesmosis appeared to be intact.  This appeared as an AO type B fracture.  However, this was not a rotational injury.,There is a posterior malleolar fragment attached to the distal fibular fragment, which appeared to be avulsed as well, but comminuted.  CT scan revealed a more serious fracture with an anterior as well as posterior plafond fracture of an anterior fragment, which was undisplaced in the posterior medial corner.  A posterior Tillaux fragment appeared to be separate.  However, in this area, there was significant comminution in the mid portion of the ankle joint.,There were many fragments and defects in this region.,The medial mortise however appeared to be intact with regards to the tibial plafond even though there was an anterior undisplaced fragment.,We discussed delayed open reduction internal fixation with the patient.  He understood the risk of surgery including infection, decreased range of motion, stiffness, neurovascular injury, weakness, and numbness.  We discussed seriously the risk of osteoarthritis because of the comminution in the intraarticular surface shown on the CT scan.  We discussed deep vein thrombosis, pulmonary embolism, skin slough, skin necrosis, infection, and need for second surgery.  We discussed shortening, decreased strength, limited use, disability of operative extremity, malunion, nonunion, compartment syndrome, stiffness of the operative extremity, numbness, and weakness.  Examination of the patient revealed that he had slightly decreased sensation on the dorsum of his foot.,The patient was able to flex and extend his toes, had good capillary refill, good dorsalis pedis, and posterior tibial pulse.,The patient's tissues were edematous and we has waited approximately 10 days before performing the surgery when the skin could be wrinkled anteriorly.  We discussed his incision, the medial incision as well as lateral incision and the lateral incision would be more posterolateral to maintain a bridge of at least 6 to 8 cm between the 2 incisions.  We did discuss the skin slough as well as skin necrosis, particularly medially where the most skin pressure was because of displacement laterally.  He understood the posterolateral comminution of the tibial plafond, which would be reduced by aligning up the cortex posteriorly.,We discussed the posterolateral approach with reduction of the fibula.  We discussed that likely the distal fibula would not be removed completely to assess the articular surface as this would likely comminute the fibula, even more fragmentation would occur, and would not be able to obtain an anatomic reduction.  He understood this distal fibular fracture was comminuted and there were missing fragments of bone because they were impacted into intramedullary cancellous space.  With this, the patient understood that the hardware may necessitate removal as well in the future.  We discussed hardware irritation.  We also discussed risk of osteoarthritis, which was nearly 100% particularly because of comminution of this area posteriorly.  With these risks discussed and listed on the consent, the patient wanted the procedure.,OPERATIVE NOTE:,  The patient was brought to operating theater and given successful general anesthetic.  His right leg was prepped and draped in the usual fashion.  Before prep and drape was performed, a close reduction was tried to be obtained to see whether there was any obstruction to reduction.  It was felt that at one point the posterior tibialis tendon may be intraarticular.,The reduction appeared to line up.  However, there was significant gap of approximately 1.5 to 2 cm between the avulsed medial malleolus fragment and distal tibia.,A lateral incision was made over the fracture site approximately 8 cm long and was taken to subcutaneous tissue.  The superficial peroneal nerve was seen and this was avoided.  The incision was placed posterolateral to fibula.,This was to ensure good flap of tissue between the 2 incisions medial and laterally.  The fracture was seen.  The fracture was elevated and medialized and de-rotated.  The anterior portion of the distal fibula was significantly comminuted with defect.  The posterior aspect was still intact.  However, there were multiple fracture lines demonstrating a crush-type injury.  This was reduced manually.  At this point, dissection was performed bluntly behind the peroneal tendons in between this and flexor hallucis longus tendon.  No sharp dissection was performed.  The posterior malleolar fragment was palpated with the distal fibula reduced.  The posterior malleolar fragment appeared to be reduced as well.,X-ray views confirmed this.,An incision was made, standard incision, curvilinear, medially distal to the medial corner of the mortise and curving anterior and posteriorly around the tip of the medial malleolus.  This was taken only through subcutaneous tissue.  The saphenous vein was found, dissected out.  Its branches were cauterized.  Penrose drain was placed around this.,Dissection was undertaken.  The periosteal tissue was seen and was invaginated into the joint.,This was recovered and flipped back on both sides.  Next, the towel clip was used.  Ends were freshened up using irrigation.  The joint surface appeared to be congruent anteriorly and posteriorly medially.,Anatomic reduction was performed in the medial malleolus using 2 mm K-wires and exchanging these for a 35 mm and a 40 mm, anterior and posterior respectively, partially threaded cancellous screws.  Anatomic reduction was gained.  X-rays were taken showing excellent anatomic reduction.  Next, attention was drawn towards the fibula.  Standard 6-hole one-third tubular plate was applied to this.  Again, this was more of a transverse impacted fracture.  Therefore, interfragmentary screw on an angle could not be used.,The posterior cortex was used to assess anatomic reduction.  Screws were placed.  It was used as a spring plate pushing the distal fibular fragment medially.,Screw holes were filled.  They were double-checked.  Screws had excellent purchase and were tightened up.  At this point, lateral views were taken as well as palpation of posterior lateral fragment was performed in the plafond.  This appeared to show anatomic reduction and did not appear to be a step on the articular surface or the posterior cortex of the distal tibia.,The screw was then placed from anterior medial to posterior lateral into this comminuted fragment.,A 2 mm K-wire was used.  Finger was placed on this fragment and the pin was advanced even before the finger.  X-ray views could show the posterior cortex and location of the pin.  This was then exchanged for a 55 mm partially threaded cancellous screw after tapping was performed.  This was double checked to ensure good positioning and this was so.  On the lateral view, we could see this was not in the joint.  AP views and mortise views showed this was not in the joint.  One could palpate this as well.  The screw was placed slightly proximal to distal in the anteroposterior plane.  At the distal tip of it, it was just in the subchondral bone but not in the joint.  There was slight to excellent purchase of this posterior lateral fragment.  Wounds were copiously irrigated followed by closing using 2-0 Vicryl in inverted fashion followed by staples to skin.  Adaptic, 4 x 4s, abdominal pad was placed on wound, held in place with Kerlix followed by an extensor bandage.  Posterior splint was placed on the patient.  The patient's leg was placed in neutral position.  Significant amount of cast padding were used and large bulky trauma ABD type dressings.  The heel was padded and leg was padded with approximately 2 inches of padding.  Tourniquet was deflated.  The patient had good capillary refill, good pulses, and the patient returned to recovery room in stable condition with no complications.  Physician assistant assisted during the case with retracting as well as holding the medial malleolar fragment and fragments in position while placement screws were applied.  Positioning of the leg was accomplished by the physician assistant.  As well, physician assistant assisted in transport of patient to and from the recovery room, assisted in cautery as well as dissection and retraction of tissue.  The patient is expected to do well overall.  He does have an area of comminution shown on the CT scan.  However, by x-rays, it appears that there is anatomic reduction gained at this posterolateral fragment.  Nonetheless, this area was crushed and the patient will have degenerative changes in the future caused by this crushing area.",
    "follow_up_items": [
      {
        "action": "Orthopedic Consult",
        "action_verbatim": "follow up",
        "period_text": "in 2 days",
        "period_date": "2025-01-17",
        "action_char_start": 1473,
        "action_char_end": 1482,
        "time_char_start": 1483,
        "time_char_end": 1492,
        "in_closed_set": true,
        "coverage_note": "in_set"
      }
    ]
  },
  {
    "note_id": 1332,
    "specialty": "SOAP / Chart / Progress Notes",
    "sample_name": "Posttransplant Lymphoproliferative Disorder",
    "visit_date_assumed": "2025-01-15",
    "transcription": "CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1.  Posttransplant lymphoproliferative disorder.,2.  Chronic renal insufficiency.,3.  Squamous cell carcinoma of the skin.,4.  Anemia secondary to chronic renal insufficiency and chemotherapy.,5.  Hypertension.,HISTORY OF PRESENT ILLNESS: , A 51-year-old white male diagnosed with PTLD in latter half of 2007.  He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia.  He did not seek medical attention immediately.  He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma.  He was discussed at the hematopathology conference.  Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started.  First cycle of chemotherapy was complicated by sepsis despite growth factor support.  He also appeared to have become disoriented either secondary to sepsis or steroid therapy.,The patient has received 5 cycles of chemotherapy to date.  He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well.  His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.,The patient is here for the sixth and final cycle of chemotherapy.  He states he feels well.  He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue.  He denies any tingling or numbness in his fingers.  Review of systems is otherwise entirely negative.,Performance status on the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit.  There is mild pallor noted.  There is no icterus, adenopathy or petechiae noted.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  Systolic flow murmur is best heard in the pulmonary area.  ABDOMEN:  Soft and nontender with no organomegaly.  Renal transplant is noted in the right lower quadrant with a scar present.  EXTREMITIES:  Reveal no edema.,LABORATORY DATA: , CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.,ASSESSMENT AND PLAN:,1.  Diffuse large B-cell lymphoma following transplantation.  The patient is to receive his sixth and final cycle of chemotherapy today.  PET scan has been ordered to be done within 2 weeks.  He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.,2.  Chronic renal insufficiency.,3.  Anemia secondary to chronic renal failure and chemotherapy.  He is to continue on his regimen of growth factor support.,4.  Hypertension.  This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled.  His CMP is pending from today.,5.  Squamous cell carcinoma of the skin.  The scalp is well healed.  He still has an open wound on the right posterior aspect of his trunk.  This has no active drainage, but it is yet to heal.  This probably will heal by secondary intention once chemotherapy is finished.  Prescription for prednisone as part of his chemotherapy has been given to him.",
    "follow_up_items": [
      {
        "action": "Blood Test",
        "action_verbatim": "CBC, CMP, and LDH",
        "period_text": null,
        "period_date": null,
        "action_char_start": 2649,
        "action_char_end": 2666,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": true,
        "coverage_note": "no_time"
      },
      {
        "action": null,
        "action_verbatim": "prednisone",
        "period_text": null,
        "period_date": null,
        "action_char_start": 834,
        "action_char_end": 844,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      }
    ]
  },
  {
    "note_id": 3895,
    "specialty": "Discharge Summary",
    "sample_name": "Pneumonia & COPD - Discharge Summary",
    "visit_date_assumed": "2025-01-15",
    "transcription": "ADMISSION DIAGNOSES:,1.  Pneumonia, likely secondary to aspiration.,2.  Chronic obstructive pulmonary disease (COPD) exacerbation.,3.  Systemic inflammatory response syndrome.,4.  Hyperglycemia.,DISCHARGE DIAGNOSES:,1.  Aspiration pneumonia.,2.  Aspiration disorder in setting of severe chronic obstructive pulmonary disease.,3.  Chronic obstructive pulmonary disease (COPD) exacerbation.,4.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.,5.  Hypercapnia on admission secondary to chronic obstructive pulmonary disease.,6.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture.,7.  Atrial fibrillation with episodic rapid ventricular rate, now rate control.,8.  Hyperglycemia secondary to poorly controlled type ii diabetes mellitus, insulin requiring.,9.  Benign essential hypertension, poorly controlled on admission, now well controlled on discharge.,10.  Aspiration disorder exacerbated by chronic obstructive pulmonary disease and acute respiratory failure.,11.  Hyperlipidemia.,12.  Acute renal failure on chronic renal failure on admission, now resolved.,HISTORY OF PRESENT ILLNESS:,  Briefly, this is 73-year-old white male with history of multiple hospital admissions for COPD exacerbation and pneumonia who presented to the emergency room on 04/23/08, complaining of severe shortness of breath.  The patient received 3 nebulizers at home without much improvement.  He was subsequently treated successfully with supplemental oxygen provided by normal nasal cannula initially and subsequently changed to BiPAP.,HOSPITAL COURSE:  ,The patient was admitted to the hospitalist service, treated with frequent small volume nebulizers, treated with IV Solu-Medrol and BiPAP support for COPD exacerbation.  The patient also noted with poorly controlled atrial fibrillation with a rate in the low 100s to mid 100s.  The patient subsequently received diltiazem, also received p.o. digoxin.  The patient subsequently responded well as well received IV antibiotics including Levaquin and Zosyn.  The patient made slow, but steady improvement over the course of his hospitalization.  The patient subsequently was able to be weaned off BiPAP during the day, but continued BiPAP at night and will continue with BiPAP if needed.  The patient may require a sleep study after discharge, but by the third day prior to discharge he was no longer utilizing BiPAP, was simply using supplemental O2 at night and was able to maintain appropriate and satisfactory O2 saturations on one-liter per minute supplemental O2 per nasal cannula.  The patient was able to participate with physical therapy, able to ambulate from his bed to the bathroom, and was able to tolerate a dysphagia 2 diet.  Note that speech therapy did provide a consultation during this hospitalization and his modified barium swallow was thought to be unremarkable and really related only to the patient's severe shortness of breath during meal time.  The patient's chest x-ray on admission revealed some mild vascular congestion and bilateral pleural effusions that appeared to be unchanged.  There was also more pronounced patchy alveolar opacity, which appeared to be, \"mass like\" in the right suprahilar region.  This subsequently resolved and the patient's infiltrate slowly improved over the course of his hospitalization.  On the day prior to discharge, the patient had a chest x-ray 2 views, which allowing for differences in technique revealed little change in the bibasilar infiltrates and atelectatic changes at the bases bilaterally.  This was compared with an examination performed 3 days prior.  The patient also had minimal bilateral effusions.  The patient will continue with clindamycin for the next 2 weeks after discharge.  Home health has been ordered and the case has been discussed in detail with Shaun Eagan, physician assistant at Eureka Community Health Center.  The patient was discharged as well on a dysphagia 2 diet, thin liquids are okay.  The patient discharged on the following medications.,DISCHARGE MEDICATIONS:,1.  Home oxygen 1 to 2 liters to maintain O2 saturations at 89 to 91% at all times.,2.  Ativan 1 mg p.o. t.i.d.,3.  Metformin 1000 mg p.o. b.i.d.,4.  Glucotrol 5 mg p.o. daily.,5.  Spiriva 1 puff b.i.d.,6.  Lantus 25 units subcu q.a.m.,7.  Cardizem CD 180 mg p.o. q.a.m.,8.  Advair 250/50 mcg, 1 puff b.i.d.  The patient is instructed to rinse with mouthwash after each use.,9.  Iron 325 mg p.o. b.i.d.,10.  Aspirin 325 mg p.o. daily.,11.  Lipitor 10 mg p.o. bedtime.,12.  Digoxin 0.25 mg p.o. daily.,13.  Lisinopril 20 mg p.o. q.a.m.,14.  DuoNeb every 4 hours for the next several weeks, then q.6 h. thereafter, dispensed 180 DuoNeb ampule's with one refill.,15.  Prednisone 40 mg p.o. q.a.m. x3 days followed by 30 mg p.o. q.a.m. x3 days, then followed by 20 mg p.o. q.a.m. x5 days, then 10 mg p.o. q.a.m. x14 days, then discontinue, #30 days supply given.  No refills.,16.  Clindamycin 300 mg p.o. q.i.d. x2 weeks, dispensed #64 with one refill.,The patient's aspiration pneumonia was discussed in detail.  He is agreeable to obtaining a chest x-ray PA and lateral after 2 weeks of treatment.  Note that this patient did not have community-acquired pneumonia.  His discharge diagnosis is aspiration pneumonia.  The patient will continue with a dysphagia 2 diet with thin liquids after discharge.  The patient discharged with home health.  A dietary and speech therapy evaluation has been ordered.  Speech therapy to treat for chronic dysphagia and aspiration in the setting of severe chronic obstructive pulmonary disease.,Total discharge time was greater than 30 minutes.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "Clindamycin 300 mg p.o. q.i.d.",
        "period_text": "x2 weeks",
        "period_date": null,
        "action_char_start": 5028,
        "action_char_end": 5058,
        "time_char_start": 5059,
        "time_char_end": 5067,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": "X-Ray",
        "action_verbatim": "chest x-ray PA and lateral",
        "period_text": "after 2 weeks of treatment",
        "period_date": null,
        "action_char_start": 5192,
        "action_char_end": 5218,
        "time_char_start": 5219,
        "time_char_end": 5245,
        "in_closed_set": true,
        "coverage_note": "in_set"
      },
      {
        "action": null,
        "action_verbatim": "speech therapy evaluation",
        "period_text": null,
        "period_date": null,
        "action_char_start": 5507,
        "action_char_end": 5532,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "referral"
      }
    ]
  },
  {
    "note_id": 3278,
    "specialty": "General Medicine",
    "sample_name": "Hyperthyroidism Following Pregnancy",
    "visit_date_assumed": "2025-01-15",
    "transcription": "HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain.  She had been previously diagnosed with hyperthyroidism.  Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm.  She had been experiencing palpitations and tachycardia.  She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3.  Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively.  Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency.  She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards.  She complained of sweating, but has experienced no diarrhea and no change in appetite.  She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:,  Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:,  She had a baby five months ago.  She smokes a half pack a day.  She denies alcohol and drug use.,MEDICATIONS:,  Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT:  She has exophthalmos and could not close her lids completely.,Cardiovascular:  tachycardia.,Neurologic:  She had mild hyperreflexiveness.,LAB:,  All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122.  Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry.  On the 2nd day of treatment, the patient still complained of chest pain.  EKG again showed tachycardia.  Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours.  The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake.  Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131.  She was to return home after the iodine treatment.  She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism.  Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism.  Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism.  She should return to Endocrine Clinic in six weeks to have thyroid function tests performed.  Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy.  Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health.  Patient was given methylcellulose ophthalmic, one drop in each eye daily.  She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression.  Patient will be continued on citalopram 10 mg.",
    "follow_up_items": [
      {
        "action": "Blood Test",
        "action_verbatim": "thyroid function tests",
        "period_text": "in six weeks",
        "period_date": "2025-02-26",
        "action_char_start": 2729,
        "action_char_end": 2751,
        "time_char_start": 2708,
        "time_char_end": 2720,
        "in_closed_set": true,
        "coverage_note": "in_set"
      },
      {
        "action": null,
        "action_verbatim": "follow up",
        "period_text": "in 6 weeks",
        "period_date": "2025-02-26",
        "action_char_start": 3136,
        "action_char_end": 3145,
        "time_char_start": 3146,
        "time_char_end": 3156,
        "in_closed_set": false,
        "coverage_note": "referral"
      },
      {
        "action": null,
        "action_verbatim": "citalopram 10 mg",
        "period_text": null,
        "period_date": null,
        "action_char_start": 3247,
        "action_char_end": 3263,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      }
    ]
  },
  {
    "note_id": 1262,
    "specialty": "Surgery",
    "sample_name": "Angiography & Catheterization - 1",
    "visit_date_assumed": "2025-01-15",
    "transcription": "INDICATION:,  Acute coronary syndrome.,CONSENT FORM: , The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him.  He understands.  All questions answered and is willing to sign consent.,PROCEDURE PERFORMED:,  Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.,NARRATIVE: , The patient was brought to the cardiac catheterization laboratory in a fasting state.  Both groins were draped and sterilized in the usual fashion.  Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery.  Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery.  Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.,FINDINGS,1.  Hemodynamics systemic blood pressure 140/70 mmHg.  LVEDP at the end of the procedure was 13 mmHg.,2.  The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery.  The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis.  The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium.  The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.,The LAD is calcified and diffusely disease in the proximal and mid portion.  There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.,3.  The right coronary artery is dominant.  It is septal to be occluded in the mid portion.,The findings were discussed with the patient and she opted for PCI.  Angiomax bolus was started.  The ACT was checked.  It was higher in 300.  I have given the patient 600 mg of oral Plavix.,The right coronary artery was engaged using a #6-French JR4 guide catheter.  I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support.  I was unable to cross with this lesion using a whisper wire.  I was unable to cross with this lesion using Cross-IT 100 wire.  I have also used second #6-French Amplatz right I guide catheter.  At one time, I have lost flow in the distal vessel.  The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.,Dr. X was notified.,Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel.  I have performed careful balloon angioplasty of the mid RCA.  I have given nitroglycerin under the nursing several times during the procedure.,I then performed arthrectomy using #5-French export catheter.,I performed more balloon predilation using a 3.0 x16 mm Voyager balloon.  I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result.  Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing.  I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.,Left ventricular catheterization was performed with #6-French angle pigtail catheter.  The left ventricle is rather smaller in size.  The mid inferior wall is minimally hypokinetic, ejection fraction is 70%.  There is no evidence of aortic wall stenosis or mitral regurgitation.,Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.,CONCLUSIONS,1.  Normal left ventricular size and function.  Ejection fraction is 65% to 70%.  No MR.,2.  Successful angioplasty and stenting of the subtotally closed mid RCA.  This was hard, organized thrombus, very difficult to penetrate.  I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result.  The RCA is dominant.,3.  No moderate disease in the distal left main.  Moderate disease in the ostium of the left circumflex artery.  Mild disease in the proximal LAD.,PLAN: , Recommend smoking cessation.  Continue aspirin lifelong and continue Plavix for at least 12 months.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "aspirin lifelong",
        "period_text": null,
        "period_date": null,
        "action_char_start": 5116,
        "action_char_end": 5132,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "Plavix for at least 12 months",
        "period_text": null,
        "period_date": null,
        "action_char_start": 5146,
        "action_char_end": 5175,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "smoking cessation",
        "period_text": null,
        "period_date": null,
        "action_char_start": 5087,
        "action_char_end": 5104,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "self_care"
      }
    ]
  },
  {
    "note_id": 3003,
    "specialty": "Nephrology",
    "sample_name": "Kidney Transplant - Followup",
    "visit_date_assumed": "2025-01-15",
    "transcription": "REASON FOR VISIT:,  Kidney transplant.,HISTORY OF PRESENT ILLNESS: , The patient is a 52-year-old gentleman with ESRD secondary to hypertension, status post kidney transplant in February 2006.  He had to back down on his WelChol because of increased backache.  He actually increased his Pravachol and is tolerating this with minimal problems.  He comes in for followup.,ALLERGIES: , Aspirin and Altace caused cough, Lipitor and Pravachol at higher doses caused myalgias, Zetia caused myalgias.,MEDICATIONS:,  Gengraf 125/50 mg daily, CellCept 500 mg q.i.d., acyclovir 800 mg q.i.d., DexFol daily, ferrous sulfate Mondays, Wednesdays and Fridays, metoprolol 50 mg b.i.d., vitamin C daily, baby aspirin 81 mg daily, Bactrim Single Strength daily, Cozaar 50 mg daily, WelChol 625 mg daily, and Pravachol 10 mg daily.,PAST MEDICAL HISTORY:,1.  ESRD secondary to hypertension.,2.  Cadaveric kidney in February 2006.,3.  Gunshot wound in Southeast Asia.,4.  Hyperlipidemia.,REVIEW OF SYSTEMS: , Cardiovascular:  No chest pain, dyspnea on exertion, orthopnea, PND or edema.  GU:  No hematuria, foamy urine, pyuria, frequency or dysuria.  He has occasional tingling over his graft, but this is not bothering him today.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Pulse 82.  Blood pressure is 108/64.  Weight is 64.5 kg.  GENERAL:  He is in no apparent distress.  HEART:  Regular rate and rhythm.  No murmurs, rubs or gallops.  LUNGS:  Clear bilaterally.  ABDOMEN:  Soft, nontender, and nondistended.  Multiple scars.  Right lower quadrant graft is unremarkable.  EXTREMITIES:  No edema.,LABORATORY DATA:,  Labs dated 07-11-06, hematocrit 34.8, sodium 137, magnesium 1.9, potassium 4.9, chloride 102, CO2 25, BUN is 37, creatinine is 1.3, calcium 10.1, phosphorus 3.7, and albumin 4.4.  LFTs unremarkable.  Cholesterol 221, triglycerides 104, HDL 42, LDL 158, and cyclosporine 163.,IMPRESSION:,1.  Status post cadaveric kidney transplant with stable function.,2.  Hypertension under excellent control.,3.  Hyperlipidemia not at goal.  He simply is not tolerating higher doses of medications.,PLAN:,1.  We will add over-the-counter fish oil b.i.d.,2.  Continue all current medications.,3.  Recheck labs today including urinalysis.,4.  He will see transplant in two weeks and me in four weeks.  We will plan to send urine for decoy cells on his next visit.",
    "follow_up_items": [
      {
        "action": "Urinalysis",
        "action_verbatim": "send urine for decoy cells",
        "period_text": "on his next visit",
        "period_date": null,
        "action_char_start": 2294,
        "action_char_end": 2320,
        "time_char_start": 2321,
        "time_char_end": 2338,
        "in_closed_set": true,
        "coverage_note": "vague"
      },
      {
        "action": null,
        "action_verbatim": "see transplant",
        "period_text": "in two weeks",
        "period_date": "2025-01-29",
        "action_char_start": 2227,
        "action_char_end": 2241,
        "time_char_start": 2242,
        "time_char_end": 2254,
        "in_closed_set": false,
        "coverage_note": "referral"
      },
      {
        "action": null,
        "action_verbatim": "and me",
        "period_text": "in four weeks",
        "period_date": "2025-02-12",
        "action_char_start": 2255,
        "action_char_end": 2261,
        "time_char_start": 2262,
        "time_char_end": 2275,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      },
      {
        "action": null,
        "action_verbatim": "fish oil b.i.d.",
        "period_text": null,
        "period_date": null,
        "action_char_start": 2116,
        "action_char_end": 2131,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      }
    ]
  },
  {
    "note_id": 4675,
    "specialty": "Cardiovascular / Pulmonary",
    "sample_name": "Selective Coronary Angiography & Angioplasty",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PREOPERATIVE DIAGNOSIS AND INDICATIONS:,  Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:,  The patient presented with an acute non-ST-elevation MI.  Despite medical therapy, she continued to have intermittent angina.  Angiography demonstrated the severe LAD as the culprit lesion.  This was treated as noted above with angioplasty alone as the stent could not be safely advanced.  She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above.  She will be continued on her medical therapy.  At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position.  The area of the right femoral artery was prepped and draped in a sterile fashion.  Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance.  With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system.  The catheter was removed.  The sheath flushed.  The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery.  The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI.  The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower.  We repeated the level and it was slightly higher.  We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV.  Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal.  An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated.  Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent.  The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium.  The balloon was inflated and removed, repeat angiography performed.  We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification.  The stent was removed.  Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful.  It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed.  Repeat angiography demonstrated no evidence of dissection.  One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal.  I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed.  The guidewires and guide cath were removed.  The sheath flushed and sutured into position.  The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:,  Aorta 185/54.,Left ventriculography was not performed.  I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels.  The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal.  The LAD has significant calcification proximally.  There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent.  This resulted in a 30% residual, mostly eccentric calcified plaque.  Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal.  This was not ballooned.  Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal.  These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal.  As noted above, this area was not stented because I could not safely advance the stent.  Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches.  The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal.  The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch.  The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch.  The remainder of the right coronary and its branches were without significant disease.",
    "follow_up_items": []
  },
  {
    "note_id": 2173,
    "specialty": "Orthopedic",
    "sample_name": "Long-Arm Cast",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PREOPERATIVE DIAGNOSIS:,  Left distal radius fracture displaced.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture displaced.,SURGERY:  ,Closed reduction and placement of long-arm cast, CPT code 25605.,ANESTHESIA:  ,General LMA.,FINDINGS:  ,The patient was found to have a displaced fracture.  She was found to be in perfect alignment after closed reduction and placement of cast.  The radial deviation was well corrected.,INDICATIONS: , The patient is 5 years old.  She was seen in our office today 1 week after being placed into a cast for a displaced fracture.  She was noted to have significant loss of alignment especially on the lateral view.  She was indicated for closed reduction and placed of the long-arm cast.  Risks and benefits were discussed at length with the family.  They wished to proceed.,PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  Previous cast was previously removed.  An arm was approached and a closed reduction was performed.  This was checked under AP and lateral projection and was found to be in adequate alignment.  There was very mild residual dorsiflexion deformity noted.,A long-arm cast was then placed with plaster and molding.  Repeat x-rays demonstrated adequate alignment on both views.,The cast was then reinforced with fiberglass.  The patient was awakened from anesthesia and taken to recovery room in good condition.  There were no complications.  All instruments, sponge, and needle counts were correct at the end of case.,PLAN:  ,The patient will be discharged home.  She will return in 3 weeks for cast removal and clinical examination.  She would likely be placed into a wrist-guard at that time.  She has a prescription for Tylenol with codeine elixir.,",
    "follow_up_items": [
      {
        "action": "Orthopedic Consult",
        "action_verbatim": "She will return",
        "period_text": "in 3 weeks",
        "period_date": "2025-02-05",
        "action_char_start": 1637,
        "action_char_end": 1652,
        "time_char_start": 1653,
        "time_char_end": 1663,
        "in_closed_set": true,
        "coverage_note": "in_set"
      }
    ]
  },
  {
    "note_id": 2487,
    "specialty": "Office Notes",
    "sample_name": "Myoclonic Epilepsy",
    "visit_date_assumed": "2025-01-15",
    "transcription": "DIAGNOSES:,1.  Juvenile myoclonic epilepsy.,2.  Recent generalized tonic-clonic seizure.,MEDICATIONS:,1.  Lamictal 250 mg b.i.d.,2.  Depo-Provera.,INTERIM HISTORY: , The patient returns for followup.  Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking.  She has not had a generalized seizure.  She is very concerned that this will occur.  Most of the myoclonus is in the mornings.  Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left.  She states that she has been very compliant with the medications and is getting a good amount of sleep.  She continues to drive.,Social history and review of systems are discussed above and documented on the chart.,PHYSICAL EXAMINATION: , Vital signs are normal.  Pupils are equal and reactive to light.  Extraocular movements are intact.  There is no nystagmus.  Visual fields are full.  Demeanor is normal.  Facial sensation and symmetry is normal.  No myoclonic jerks noted during this examination.  No myoclonic jerks provoked by tapping on her upper extremity muscles.  Negative orbit.  Deep tendon reflexes are 2 and symmetric.  Gait is normal.  Tandem gait is normal.  Romberg negative.,IMPRESSION AND PLAN:,  Recurrence of early morning myoclonus despite high levels of Lamictal.  She is tolerating the medication well and has not had a generalized tonic-clonic seizure.  She is concerned that this is a precursor for another generalized seizure.  She states that she is compliant with her medications and has had a normal sleep-wake cycle.,Looking back through her notes, she initially responded very well to Keppra, but did have a breakthrough seizure on Keppra.  This was thought secondary to severe insomnia when her baby was very young.  Because she tolerated the medication well and it was at least partially affective, I have recommended adding Keppra 500 mg b.i.d.  Side effect profile of this medication was discussed with the patient.,I will see in followup in three months.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "Keppra 500 mg b.i.d.",
        "period_text": null,
        "period_date": null,
        "action_char_start": 1898,
        "action_char_end": 1918,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": "Neurology Consult",
        "action_verbatim": "see in followup",
        "period_text": "in three months",
        "period_date": "2025-04-15",
        "action_char_start": 1998,
        "action_char_end": 2013,
        "time_char_start": 2014,
        "time_char_end": 2029,
        "in_closed_set": true,
        "coverage_note": "in_set"
      }
    ]
  },
  {
    "note_id": 1381,
    "specialty": "SOAP / Chart / Progress Notes",
    "sample_name": "Gen Med Progress Note - 9",
    "visit_date_assumed": "2025-01-15",
    "transcription": "SUBJECTIVE:,  The patient is a 44-year-old white female who is here today with multiple problems.  The biggest concern she has today is her that left leg has been swollen.  It is swollen for three years to some extent, but worse for the past two to three months.  It gets better in the morning when she is up, but then through the day it begins to swell again.  Lately it is staying bigger and she somewhat uncomfortable with it being so large.  The right leg also swells, but not nearly like the left leg.  The other problem she had was she has had pain in her shoulder and back.  These occurred about a year ago, but the pain in her left shoulder is of most concern to her.  She feels like the low back pain is just a result of a poor mattress.  She does not remember hurting her shoulder, but she said gradually she has lost some mobility.  It is hard time to get her hands behind her back or behind her head.  She has lost strength in the left shoulder.  As far as the blood count goes, she had an elevated white count.  In April of 2005, Dr. XYZ had asked Dr. XYZ to see her because of the persistent leukocytosis; however, Dr. XYZ felt that this was not a problem for the patient and asked her to just return here for follow up.  She also complains of a lot of frequency with urination and nocturia times two to three.  She has gained weight; she thinks about 12 pounds since March.  She now weighs 284.  Fortunately, her blood pressure is staying stable.  She takes atenolol 12.5 mg per day and takes Lasix on a p.r.n. basis, but does not like to take it because it causes her to urinate so much.  She denies chest pain, but she does feel like she is becoming gradually more short of breath.  She works for the city of Wichita as bus dispatcher, so she does sit a lot, and just really does not move around much.  Towards the end of the day her leg was really swollen.  I reviewed her lab work.  Other than the blood count her lab work has been pretty normal, but she does need to have a cholesterol check.,OBJECTIVE:,General:  The patient is a very pleasant 44-year-old white female quite obese.,Vital Signs:  Blood pressure:  122/70.  Temperature:  98.6.,HEENT:  Head:  Normocephalic.  Ears:  TMs intact.  Eyes:  Pupils round, and equal.  Nose:  Mucosa normal.  Throat:  Mucosa normal.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft and obese.,Extremities:  A lot of fluid in both legs, but especially the left leg is really swollen.  At least 2+ pedal edema.  The right leg just has a trace of edema.  She has pain in her low back with range of motion.  She has a lot of pain in her left shoulder with range of motion.  It is hard for her to get her hand behind her back.  She cannot get it up behind her head.  She has pain in the anterior left shoulder in that area.,ASSESSMENT:,1.  Multiple problems including left leg swelling.,2.  History of leukocytosis.,3.  Joint pain involving the left shoulder, probably impingement syndrome.,4.  Low back pain, chronic with obesity.,5.  Obesity.,6.  Frequency with urination.,7.  Tobacco abuse.,PLAN:,1.  I will schedule for a venous Doppler of the left leg and will have her come back in the morning for a CBC and a metabolic panel.  We will start her on Detrol 0.4 mg one daily and also started on Mobic 15 mg per day.,2.  Elevate her leg as much as possible and wear support hose if possible.  Keep her foot up during the day.  We will see her back in two weeks.  We will have the results of the Doppler, the lab work and see how she is doing with the Detrol and the joint pain.  If her shoulder pain is not any better, we probably should refer her on over to orthopedist.  We did do x-rays of her shoulder today that did not show anything remarkable.  See her in two weeks or p.r.n.",
    "follow_up_items": [
      {
        "action": "Blood Test",
        "action_verbatim": "CBC and a metabolic panel",
        "period_text": "in the morning",
        "period_date": null,
        "action_char_start": 3176,
        "action_char_end": 3201,
        "time_char_start": 279,
        "time_char_end": 293,
        "in_closed_set": true,
        "coverage_note": "in_set"
      },
      {
        "action": null,
        "action_verbatim": "venous Doppler of the left leg",
        "period_text": null,
        "period_date": null,
        "action_char_start": 3096,
        "action_char_end": 3126,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "no_time"
      },
      {
        "action": null,
        "action_verbatim": "Detrol 0.4 mg one daily",
        "period_text": null,
        "period_date": null,
        "action_char_start": 3225,
        "action_char_end": 3248,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "see her back",
        "period_text": "in two weeks",
        "period_date": "2025-01-29",
        "action_char_start": 3408,
        "action_char_end": 3420,
        "time_char_start": 3421,
        "time_char_end": 3433,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      }
    ]
  },
  {
    "note_id": 1382,
    "specialty": "SOAP / Chart / Progress Notes",
    "sample_name": "Gen Med Progress Note - 2",
    "visit_date_assumed": "2025-01-15",
    "transcription": "CHIEF COMPLAINT:,  Followup on hypertension and hypercholesterolemia.,SUBJECTIVE:,  This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago.  He has done well with that.  He does most of the things that he wants to do.  He travels at every chance he has, and he just got back from a cruise.  He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations.  He sees Dr. Ferguson.  He is known to have Crohn's and he takes care of that for him.  He sees Dr. Roszhart for his prostate check.  He is a nonsmoker and denies swelling in his ankles.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION:, ,Vitals:  Wt; 172 lbs, up 2 lbs,  B/P; 150/60, T; 96.4, P; 72 and regular.  ,General:  A 78-year-old male who does not appear to be in any acute distress.  Glasses.  Good dentition.,CV: Distant S1, S2 without murmur or gallop. No carotid bruits. P: 2+ all around.,Lungs: Diminished with increased AP diameter. ,Abdomen:  Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted.,Extremities:  Well-healed surgical scar on the right knee.  No edema.  Hand grasps are strong and equal.,Back:  Surgical scar on the lower back.,Neuro: Intact.  A&O. Moves all four with no focal motor or sensory deficits.,IMPRESSION:,1.  Hypertension.,2.  Hypercholesterolemia.,3.  Osteoarthritis.,4.  Fatigue.,PLAN:,  We will check a BMP, lipid, liver profile, CPK, and CBC.  Refill his medications x 3 months.  I gave him a copy of Partners in Prevention.  Increase his Altace to 5 mg day for better blood pressure control.  Diet, exercise, and weight loss, and we will see him back in three months and p.r.n.",
    "follow_up_items": [
      {
        "action": "Blood Test",
        "action_verbatim": "BMP, lipid, liver profile, CPK, and CBC",
        "period_text": null,
        "period_date": null,
        "action_char_start": 1509,
        "action_char_end": 1548,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": true,
        "coverage_note": "no_time"
      },
      {
        "action": "Lipid Panel",
        "action_verbatim": "lipid",
        "period_text": null,
        "period_date": null,
        "action_char_start": 1514,
        "action_char_end": 1519,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": true,
        "coverage_note": "no_time"
      },
      {
        "action": null,
        "action_verbatim": "Increase his Altace to 5 mg day",
        "period_text": null,
        "period_date": null,
        "action_char_start": 1633,
        "action_char_end": 1664,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "see him back",
        "period_text": "in three months",
        "period_date": "2025-04-15",
        "action_char_start": 1746,
        "action_char_end": 1758,
        "time_char_start": 1759,
        "time_char_end": 1774,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      }
    ]
  },
  {
    "note_id": 3036,
    "specialty": "Nephrology",
    "sample_name": "CT Abdomen & Pelvis - 3",
    "visit_date_assumed": "2025-01-15",
    "transcription": "EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:,  Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis.  There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the solid abdominal organs.  Cardiomegaly and atherosclerotic calcifications are seen.,Hepatomegaly is observed.  There is calcification within the right lobe of the liver likely related to granulomatous changes.  Subtle irregularity of the liver contour is noted, suggestive of cirrhosis.  There is splenomegaly seen.  There are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst.  The pancreas appears atrophic.  There is a left renal nodule seen, which measures 1.9 cm with a Hounsfield unit density of approximately 29, which is indeterminate.,There is mild bilateral perinephric stranding.  There is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma.  There is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination.  Bilateral ureters appear normal in caliber along their visualized course.  The bladder is partially distended with urine, but otherwise unremarkable.,Postsurgical changes of hysterectomy are noted.  There are pelvic phlebolith seen.  There is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,Scattered colonic diverticula are observed.  The appendix is within normal limits.  The small bowel is unremarkable.  There is an anterior abdominal wall hernia noted containing herniated mesenteric fat.  The hernia neck measures approximately 2.7 cm.  There is stranding of the fat within the hernia sac.,There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis.  Degenerative changes of the spine are observed.,IMPRESSION:,1.  Anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2.  Nodule in the left lower lobe, recommend follow up in 3 months.,3.  Indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol CT or MRI.,4.  Hepatomegaly with changes suggestive of cirrhosis.  There is also splenomegaly observed.,5.  Low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6.  Fat density lesion in the left kidney, likely represents angiomyolipoma.,7.  Fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "follow up",
        "period_text": "in 3 months",
        "period_date": "2025-04-15",
        "action_char_start": 2336,
        "action_char_end": 2345,
        "time_char_start": 2346,
        "time_char_end": 2357,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      },
      {
        "action": "MRI",
        "action_verbatim": "MRI",
        "period_text": null,
        "period_date": null,
        "action_char_start": 2462,
        "action_char_end": 2465,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": true,
        "coverage_note": "no_time"
      }
    ]
  },
  {
    "note_id": 2075,
    "specialty": "Orthopedic",
    "sample_name": "Physical Therapy - Synovitis",
    "visit_date_assumed": "2025-01-15",
    "transcription": "DIAGNOSIS:,  Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain.  The patient states that on 10/02/08, the patient fell in a grocery store.  He reports slipping on a grape that was on the floor.  The patient states he went to the emergency room and then followed up with his primary care physician.  The patient was then ultimately referred to Physical Therapy.  After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs.  The report was available at the time of the evaluation.  The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1.  Tramadol.,2.  Diclofenac.,3.  Advil.,4.  Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation.  The patient does deny pain at night.  The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES:  ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE:  ,Upon observation, the patient is ambulating with a significant antalgic gait pattern.  However, he is not using any assistive device.  The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion.  Right knee active range of motion is 0 to 126 degrees.,STRENGTH:  ,Strength is 3/5 for left knee, 4+/5 for right knee.  The patient denies any pain upon light and deep palpation at the knee joints.  There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint.  The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS:  ,The patient performed a six-minute walk test.  He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:,  The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1.  Increased pain.,2.  Decreased range of motion.,3.  Decreased strength.,4.  Decreased ability to perform functional activities and work tasks.,5.  Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1.  Patient will demonstrate independence with the home exercise program.,2.  Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3.  The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4.  The patient will demonstrate 4/5 strength for the left knee.,5.  The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1.  The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2.  The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3.  Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4.  The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS:  ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1.  Therapeutic exercise with home exercise program.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "Therapeutic exercise",
        "period_text": "for six weeks",
        "period_date": null,
        "action_char_start": 4092,
        "action_char_end": 4112,
        "time_char_start": 4055,
        "time_char_end": 4068,
        "in_closed_set": false,
        "coverage_note": "recurring_schedule"
      }
    ]
  },
  {
    "note_id": 4320,
    "specialty": "Consult - History and Phy.",
    "sample_name": "Hypertension & Cardiomyopathy",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PROBLEMS LIST:,1.  Nonischemic cardiomyopathy.,2.  Branch vessel coronary artery disease.,3.  Congestive heart failure, NYHA Class III.,4.  History of nonsustained ventricular tachycardia.,5.  Hypertension.,6.  Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications.  However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest.  He has history of orthopnea and PND.  He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain.  He has occasional nausea, but no vomiting.  His appetite has decreased.  No joint pain, TIA, seizure or syncope.  Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:,  I reviewed his medication list in the chart.  He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07.  HEENT:  Atraumatic and normocephalic.  No pallor, icterus or cyanosis.  NECK:  Supple.  Jugular venous distention 5 cm above the clavicle present.  No thyromegaly.  LUNGS:  Clear to auscultation.  No rales or rhonchi.  Pulse ox was 98% on room air.  CVS:  S1 and S2 present.  S3 and S4 present.  ABDOMEN:  Soft and nontender.  Liver is palpable 5 cm below the right subcostal margin.  EXTREMITIES:  No clubbing or cyanosis.  A 1+ edema present.,ASSESSMENT AND PLAN:,  The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease.  Clinically, he is in NYHA Class III.  He has some volume overload and was not unfortunately taking Lasix as prescribed.  I have advised him to take Lasix 40 mg p.o. b.i.d.  I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d.  I advised him to continue to take Toprol and lisinopril.  I have also added Aldactone 25 mg p.o. daily for survival advantage.  I reinforced the idea of not using cocaine.  He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine.  I encouraged him to find a primary care provider.  He will come for a BMP check in one week.  I asked him to check his blood pressure and weight.  I discussed medication changes and gave him an updated list.  I have asked him to see a gastroenterologist for hepatitis C.  At this point, his Medicaid is pending.  He has no insurance and finds hard to find a primary care provider.  I will see him in one month.  He will have his fasting lipid profile, AST, and ALT checked in one week.",
    "follow_up_items": [
      {
        "action": "Blood Test",
        "action_verbatim": "BMP check",
        "period_text": "in one week",
        "period_date": "2025-01-22",
        "action_char_start": 2643,
        "action_char_end": 2652,
        "time_char_start": 2653,
        "time_char_end": 2664,
        "in_closed_set": true,
        "coverage_note": "in_set"
      },
      {
        "action": "Lipid Panel",
        "action_verbatim": "fasting lipid profile",
        "period_text": "in one week",
        "period_date": "2025-01-22",
        "action_char_start": 3002,
        "action_char_end": 3023,
        "time_char_start": 2653,
        "time_char_end": 2664,
        "in_closed_set": true,
        "coverage_note": "in_set"
      },
      {
        "action": null,
        "action_verbatim": "Lasix 40 mg p.o. b.i.d.",
        "period_text": null,
        "period_date": null,
        "action_char_start": 2180,
        "action_char_end": 2203,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "hydralazine from 75 mg t.i.d. to 100 mg t.i.d.",
        "period_text": null,
        "period_date": null,
        "action_char_start": 2234,
        "action_char_end": 2280,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "Aldactone 25 mg p.o. daily",
        "period_text": null,
        "period_date": null,
        "action_char_start": 2358,
        "action_char_end": 2384,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": "GI Consult",
        "action_verbatim": "see a gastroenterologist for hepatitis C",
        "period_text": null,
        "period_date": null,
        "action_char_start": 2802,
        "action_char_end": 2842,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": true,
        "coverage_note": "no_time"
      },
      {
        "action": null,
        "action_verbatim": "see him",
        "period_text": "in one month",
        "period_date": "2025-02-15",
        "action_char_start": 2962,
        "action_char_end": 2969,
        "time_char_start": 2970,
        "time_char_end": 2982,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      }
    ]
  },
  {
    "note_id": 4015,
    "specialty": "Dermatology",
    "sample_name": "Excision - Skin Neoplasm",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PREOPERATIVE DIAGNOSES:,1.  Enlarging nevus of the left upper cheek.,2.  Enlarging nevus 0.5 x 1 cm, left lower cheek.,3.  Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.,TITLE OF PROCEDURES:,1.  Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.,2.  Excision of the left lower cheek skin neoplasm 0.5 x 1 cm with a two layer plastic closure.,3.  Shave excision of the right nasal ala 0.5 x 1 cm skin neoplasm.,ANESTHESIA:  ,Local.  I used a total of 5 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,COMPLICATIONS:,  None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  Risks including but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures have been all reviewed.  Each of these lesions appears to be benign nevi; however, they have been increasing in size.  The lesions involving the left upper and lower cheek appear to be deep.  These required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision.  Each of these lesions was marked.  The skin was cleaned with a sterile alcohol swab.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,Began first excision of the left upper cheek skin lesion.  This was excised with the 15-blade full thickness.  Once it was removed in its entirety, undermining was performed, and the wound was closed with 5-0 myochromic for the deep subcutaneous, 5-0 nylon interrupted for the skin.,The lesion of the lower cheek was removed in a similar manner.  Again, it was excised with a 15 blade with two layer plastic closure.  Both these lesions appear to be fairly deep nevi.,The right nasal ala nevus was superficially shaved using the radiofrequency wave unit.  Each of these lesions was sent as separate specimens.  The patient was discharged from my office in stable condition.  He had minimal blood loss.  The patient tolerated the procedure very well.  Postop care instructions were reviewed in detail.  We have scheduled a recheck in one week and we will make further recommendations at that time.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "recheck",
        "period_text": "in one week",
        "period_date": "2025-01-22",
        "action_char_start": 2295,
        "action_char_end": 2302,
        "time_char_start": 2303,
        "time_char_end": 2314,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      }
    ]
  },
  {
    "note_id": 4494,
    "specialty": "Consult - History and Phy.",
    "sample_name": "Consult - Hydronephrosis",
    "visit_date_assumed": "2025-01-15",
    "transcription": "CHIEF COMPLAINT:,  Right hydronephrosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma.  She is scheduled to undergo mastectomy in two weeks.  In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation.  Again, she is scheduled for mastectomy in two weeks.  She underwent a recent PET scan for Dr. X, which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney.  There was no dilation of the right ureter noted.  Urinalysis today is microscopically negative.,PAST MEDICAL HISTORY: , Uterine cancer, mesothelioma, breast cancer, diabetes, hypertension.,PAST SURGICAL HISTORY: , Lumpectomy, hysterectomy.,MEDICATIONS:,  Diovan HCT 80/12.5 mg daily, metformin 500 mg daily.,ALLERGIES:,  None.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  She is retired.  Does not smoke or drink.,REVIEW OF SYSTEMS:,  I have reviewed his review of systems sheet and it is on the chart.,PHYSICAL EXAMINATION:,  Please see the physical exam sheet I completed.  Abdomen is soft, nontender, nondistended, no palpable masses, no CVA tenderness.,IMPRESSION AND PLAN: , Marked right hydronephrosis without hydruria.  She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005.  I will try to obtain the report to see if the right kidney was evaluated at that time.  She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney.  She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed.  She will call us back to schedule the x-rays.  She understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer.  There is also a question of a stone present in the kidney.  She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "IVP and renal scan",
        "period_text": null,
        "period_date": null,
        "action_char_start": 1575,
        "action_char_end": 1593,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "out_of_ontology"
      },
      {
        "action": null,
        "action_verbatim": "x-rays",
        "period_text": null,
        "period_date": null,
        "action_char_start": 1839,
        "action_char_end": 1845,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "vague"
      }
    ]
  },
  {
    "note_id": 1326,
    "specialty": "SOAP / Chart / Progress Notes",
    "sample_name": "Progress Note - Liver Cirrhosis",
    "visit_date_assumed": "2025-01-15",
    "transcription": "HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old Hispanic male who was seen initially in the office February 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.  The patient at that time stated that he had established diagnosis of liver cirrhosis.  Since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before, Dr. X in Las Cruces and his primary care physician in Silver City, and unfortunately we did not get any information from anybody.  Also the patient had admission in Gila Medical Center with epigastric pain, diarrhea, and confusion.  He spent 3 days in the hospital.  He was followed by Dr. X and unfortunately we also do not have the information of what was wrong with the patient.  From the patient's report he was diagnosed with some kind of viral infection.  At the time of admission he had a lot of epigastric pain, nausea, vomiting, fever, and chills.,PHYSICAL EXAMINATION,VITAL SIGNS:  Weight 107, height 6 feet 1 inch, blood pressure 128/67, heart rate 74, saturation 98%; pain is 3/10 with localization of the pain in the epigastric area.,HEENT:  PERRLA.  EOM intact.  Oropharynx is clear of lesions.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.,LUNGS:  Clear to auscultation and percussion bilateral.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs, rubs, or gallops.,ABDOMEN:  Not tender, not distended.  Splenomegaly about 4 cm under the costal margin.  No hepatomegaly.  Bowel sounds present.,MUSCULOSKELETAL:  No cyanosis, no clubbing, no pitting edema.,NEUROLOGIC:  Nonfocal.  No asterixis.  No costovertebral tenderness.,PSYCHE:  The patient is oriented x4, alert and cooperative.,LABORATORY DATA: , We were able to collect lab results from Medical Center; we got only CMP from the hospital which showed glucose level 79, BUN 9, creatinine 0.6, sodium 136, potassium 3.5, chloride 104, CO2 23.7, calcium 7.3, total protein 5.9, albumin 2.5, total bilirubin 5.63.  His AST 56, ALT 37, alkaline phosphatase 165, and his ammonia level was 53.  We do not have any other results back.  No hepatitis panels.  No alpha-fetoprotein level.  The patient told me today that he also got an ultrasound of the abdomen and the result was not impressive, but we do not have this result despite calling medical records in the hospital to release this information.,ASSESSMENT AND PLAN:,  The patient is a 55-year-old with established diagnosis of liver cirrhosis, unknown cause.,1.  Epigastric pain.  The patient had chronic pain syndrome, he had multiple back surgeries, and he has taken opiate for a prolonged period of time.  In the office twice the patient did not have any abdominal pain on physical exam.  His pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously.  He probably requires increased level of pain control with increased dose of opiates, which should be addressed with his primary care physician.,2.  End-stage liver disease.  Of course, we need to find out the cause of the liver cirrhosis.  We do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before.  We do not have any information of any type of investigation in the past.  Again, patient was seen by gastroenterologist already in Las Cruces, Dr. X.  The patient was advised to contact Dr. X by himself to convince him to send available information because we already send release information form signed by the patient without any result.  It will be not reasonable to repeat unnecessary tests in that point in time.,We are waiting for the hepatitis panel and alpha-fetoprotein level.  We will also need to get information about ultrasound which was done in Gila Medical Center, but obviously no tumor was found on this exam of the liver.  We have to figure out hepatitis status for another reason if he needs vaccination against hepatitis A and B.  Until now we do not know exactly what the cause of the patient's end-stage liver disease is and my differential diagnosis probably is hepatitis C.  The patient denied any excessive alcohol intake, but I could not preclude alcohol-related liver cirrhosis also.  We will need to look for nuclear antibody if it is not done before.  PSC is extremely unlikely but possible.  Wilson disease also possible diagnosis but again, we first have to figure out if these tests were done for the patient or not.  Alpha1-antitrypsin deficiency will be extremely unlikely because the patient has no lung problem.  On his end-stage liver disease we already know that he had low platelet count splenomegaly.  We know that his bilirubin is elevated and albumin is very low.  I suspect that at the time of admission to the hospital the patient presented with encephalopathy.  We do not know if INR was checked to look for coagulopathy.  The patient had an EGD in 2005 as well as colonoscopy in Silver City.  We have to have this result to evaluate if the patient had any varices and if he needs any intervention for that.,At this point in time, I recommended the patient to continue to take lactulose 50 mL 3 times daily.  The patient tolerated it well; no diarrhea at this point in time.  I also recommended for him to contact his primary care physician for increased dose of opiates for him.  As a primary prophylaxis of GI bleeding in patient with end-stage liver disease we will try to use Inderal.  The patient got a prescription for 10 mg pills.  He will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25% from 75% to probably 60-58.  The patient was educated how to use Inderal and he was explained why we decided to use this medication.  The patient will hold this medication if he is orthostatic or bradycardic.,Again, the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests I mentioned above.,We also discussed nutrition issues.  The patient was provided information that his protein intake is supposed to be about 25 g per day.  He was advised not to over-eat protein and advised not to starve.  He also was advised to stay away from alcohol.  His next visit is in 2 weeks with all results available.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "Inderal",
        "period_text": null,
        "period_date": null,
        "action_char_start": 5495,
        "action_char_end": 5502,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "next visit",
        "period_text": "in 2 weeks",
        "period_date": "2025-01-29",
        "action_char_start": 6030,
        "action_char_end": 6040,
        "time_char_start": 6041,
        "time_char_end": 6051,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      }
    ]
  },
  {
    "note_id": 3011,
    "specialty": "Nephrology",
    "sample_name": "Fistulogram & Angioplasty",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1.  Left arm fistulogram.,2.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3.  Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:,  Sedation with local.,COMPLICATIONS:,  None.,CONDITION:,  Fair.,DISPOSITION:,  PACU.,ACCESS SITE:,  Left upper arm brachiocephalic fistula.,SHEATH SIZE: , 5 French.,CONTRAST TYPE: , JC PEG tube 70.,CONTRAST VOLUME: , 48 mL.,FLUOROSCOPY TIME: , 16 minutes.,INDICATION FOR PROCEDURE: , This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed.  The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound.  The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate.  A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis.  The patient presents today for a left arm fistulogram with angioplasty.  The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.,PROCEDURE DETAILS:  ,The patient was brought to the angio suite and laid supine on the table.  After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion.  Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure.  The patient was given 1 g of IV Ancef prior to incision.,The left brachiocephalic fistula was visualized with bevel ultrasound.  The cephalic vein in the proximal upper arm region appeared to be of adequate caliber.  There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis.  The cephalic vein in the proximal forearm region was easily compressible.  The skin overlying the vessel was injected with 1% lidocaine solution.  A small incision was made with the #11 blade.  The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath.  The sheath was advanced over the wire.  A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis.  The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire.  The sheath was aspirated and flushed with heparinized saline solution.  A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery.  A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery.  After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table.  This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated.  The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement.  However, there is still a remainder of residual stenosis.  The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed.  The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis.  The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery.  A 4 x 20 mm cutting balloon was obtained and prepped on the back table.  The 5 French sheath was then exchanged for a 6 French sheath.  The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg.  The balloon was then deflated and removed over the wire.  A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg.  A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis.  The patient actually had a nice palpable thrill at this point.  The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis.  The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.,After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound.  The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution.  A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein.  A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence.  The 5 French introducer sheath was then exchanged for a 5 French sheath.  The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis.  The balloon was inflated to 14 mmHg.  The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results.  The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes.  After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied.  The patient tolerated the procedure without any complications.  I was present for the entire case.  The sponge, instrument, and needle counts are correct at the end of the case.  The patient was subsequently taken to PACU in stable condition.,ANGIOGRAPHIC FINDINGS:,  The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein.  After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis.  Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.,Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein.  Postangioplasty demonstrated excellent results with the standard balloon.  There was no evidence of any contrast extravasation.,IMPRESSION,1.  High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally.  Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.,2.  A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein.  Poststandard balloon angioplasty demonstrated excellent results.  No evidence of contrast extravasation.",
    "follow_up_items": []
  },
  {
    "note_id": 4214,
    "specialty": "Consult - History and Phy.",
    "sample_name": "OB/GYN Consultation - 2",
    "visit_date_assumed": "2025-01-15",
    "transcription": "She started her periods at age 13.  She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice.  She describes the pain as bilateral, intermittent, and non-radiating.  It decreases slightly when she eats and increases with activity.  She states the pain when it comes can last for half-a-day.  It is not associated with movement, but occasionally the pain was so bad that it was associated with vomiting.  She has tried LactAid, which initially helped, but then the pain returned.  She has tried changing her diet and Pepcid AC.  She was seen at XYZ where blood work was done.  At that time, she had a normal white count and a normal H&H.  She was given muscle relaxants, which did not work.,Approximately two weeks ago, she was seen in the emergency room at XYZ where a pelvic ultrasound was done.  This showed a 1.9 x 1.4-cm cyst on the right with no free fluid.  The left ovary and uterus appeared normal.  Two days later, the pain resolved and she has not had a recurrence.  She denies constipation and diarrhea.  She has had some hot flashes, but has not taken her temperature.,In addition, she states that her periods have been very irregular coming between four and six weeks.  They are associated with cramping which she is not happy about.,She has never had a pelvic exam.  She states she is not sexually active and declined having her mother leave the room, so she was not questioned regarding this without her mother present.  She is very interested in not having pain with her periods and if this was a cyst that caused her pain, she is interested in starting birth control pills to prevent this from happening again.,PAST MEDICAL HX:  ,Pneumonia in 2002, depression diagnosed in 2005, and seizures as an infant.,PAST SURGICAL HX:  ,Plastic surgery on her ear after a dog bite in 1997.,MEDICATIONS:  ,Zoloft 50 mg a day and LactAid.,ALLERGIES:  ,NO KNOWN DRUG ALLERGIES.,SOCIAL HX: , She enjoys cooking and scrapbooking.  She does have a boyfriend; again she states she is not sexually active.  She also states that she exercises regularly, does not smoke cigarettes, use drugs, or drink alcohol.,FAMILY HX: , Significant for her maternal grandfather with adult-onset diabetes, a maternal grandmother with hypertension, mother with depression, and a father who died of colon cancer at 32 years of age.  She also has a paternal great grandfather who was diagnosed with colon cancer.,PE: , VITALS: Height: 5 feet 5 inches.  Weight: 190 lb.  Blood Pressure: 120/88.  GENERAL: She is well-developed, well-nourished with normal habitus and no deformities.  NECK: Without thyromegaly or lymphadenopathy.  LUNGS: Clear to auscultation bilaterally.  HEART: Regular rate and rhythm without murmurs.  ABDOMEN: Soft, nontender, and nondistended.  There is no organomegaly or lymphadenopathy.  PELVIC: Deferred.,A/P: , Abdominal pain, unclear etiology.  I expressed my doubt that her pain was secondary to this 1.9-cm ovarian cyst given the fact that there was no free fluid surrounding this.  However, given that she has irregular periods and they are painful for her, I think it is reasonable to start her on a low-dose birth control pill.  She has no personal or familial contraindications to start this.  She was given a prescription for Lo/Ovral, dispensed 30 with refill x 4.  She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns.,If she should have the recurrence of her pain, I have advised her to call.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "Lo/Ovral",
        "period_text": null,
        "period_date": null,
        "action_char_start": 3302,
        "action_char_end": 3310,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "blood pressure check",
        "period_text": "in six weeks",
        "period_date": "2025-02-26",
        "action_char_start": 3379,
        "action_char_end": 3399,
        "time_char_start": 3362,
        "time_char_end": 3374,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      },
      {
        "action": null,
        "action_verbatim": "followup on her pain",
        "period_text": "in six months",
        "period_date": "2025-07-15",
        "action_char_start": 3428,
        "action_char_end": 3448,
        "time_char_start": 3411,
        "time_char_end": 3424,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      }
    ]
  },
  {
    "note_id": 1344,
    "specialty": "SOAP / Chart / Progress Notes",
    "sample_name": "Ophthalmology Progress Note - 1",
    "visit_date_assumed": "2025-01-15",
    "transcription": "She is stable at this time and does not require any intervention at today's visit.  I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "followup dilated examination",
        "period_text": "in six months",
        "period_date": "2025-07-15",
        "action_char_start": 132,
        "action_char_end": 160,
        "time_char_start": 111,
        "time_char_end": 124,
        "in_closed_set": false,
        "coverage_note": "referral"
      }
    ]
  },
  {
    "note_id": 2781,
    "specialty": "Neurology",
    "sample_name": "Physical Therapy - Brain Tumor Removal",
    "visit_date_assumed": "2025-01-15",
    "transcription": "DIAGNOSIS:,  Status post brain tumor removal.,HISTORY:,  The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal.  The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness.  The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications.  The patient reports that she was admitted to Hospital on 12/05/08.  At that time, they found massive swelling on the brain and a second surgery was performed.  The patient then remained in acute rehab until she was discharged to home on 01/05/09.  The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS:  ,Coumadin, Keppra, Decadron, and Glucophage.,SUBJECTIVE: , The patient reports that the pain is not an issue at this time.  The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.,PATIENT GOAL:  ,To increase strength in her left leg for better balance and walking.,OBJECTIVE:,RANGE OF MOTION:  Bilateral lower extremities are within normal limits.,STRENGTH:  Bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5.,BALANCE:  The patient's balance was assessed with a Berg balance test.  The patient has got 46/56 points, which places her at moderate risk for falls.,GAIT:  The patient ambulates with contact guard assist.  The patient ambulates with a reciprocal gait pattern with good bilateral foot clearance.  However, the patient has been reports that with increased fatigue, left footdrop tends to occur.  A 6-minute walk test will be performed at the next visit due to time constraints.,ASSESSMENT: , The patient is a 64-year-old female referred to Physical Therapy status post brain surgery.  Examination indicates deficits in strength, balance, and ambulation.  The patient will benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: , The patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks.  Interventions include:,1.  Therapeutic exercise.,2.  Balance training.,3.  Gait training.,4.  Functional mobility training.,SHORT TERM GOAL TO BE COMPLETED IN 4 WEEKS:,1.  The patient is to tolerate 30 repetitions of all lower extremity exercises.,2.  The patient is to improve balance with a score of 50/56 points.,3.  The patient is to ambulate 1000 feet in a 6-minute walk test with standby assist.,LONG TERM GOAL TO BE ACHIEVED IN 8 WEEKS:,1.  The patient is to ambulate independently within her home and standby to general supervision within the community.,2.  Berg balance test to be 52/56.,3.  The patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas.,4.  The patient is to demonstrate safely stepping over and around objects without loss of balance.,Prognosis for the above-stated goals is good.  The above treatment plan has been discussed with the patient and her husband.  They are in agreement.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "Therapeutic exercise",
        "period_text": "4 additional weeks",
        "period_date": null,
        "action_char_start": 2295,
        "action_char_end": 2315,
        "time_char_start": 2247,
        "time_char_end": 2265,
        "in_closed_set": false,
        "coverage_note": "recurring_schedule"
      },
      {
        "action": null,
        "action_verbatim": "ambulate independently",
        "period_text": "8 WEEKS",
        "period_date": "2025-03-12",
        "action_char_start": 2734,
        "action_char_end": 2756,
        "time_char_start": 2703,
        "time_char_end": 2710,
        "in_closed_set": false,
        "coverage_note": "recurring_schedule"
      }
    ]
  },
  {
    "note_id": 4860,
    "specialty": "Cardiovascular / Pulmonary",
    "sample_name": "Complex Cyanotic Congenital Heart Disease",
    "visit_date_assumed": "2025-01-15",
    "transcription": "HISTORY:,  The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.  He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation.  These procedures were performed at Medical College Hospital.  Family states that they moved to the United States.  Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery.  He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg.  The QP:QS ratio of 0.6:1.  A large decompressing venous collateral was also appreciated.  The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta.  A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful.  Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein.  Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire.  This catheter then also advanced into the bridging innominate vein.  The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava.  A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery.  There was no vascular continuity to the stump of the right Glenn.  The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava.  The Bernstein catheter was then reintroduced using a Terumo guidewire.  Probing of the superior vena cava facilitated access into the right lower pulmonary artery.  The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis.  The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length.  The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist.  This facilitated advancement of a flexor sheath into the proximal portion of the stenosis.  A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe.  A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist.  Angiogram demonstrated a good stent apposition to the caval wall.  Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist.  Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery.  The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery.  Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery.  Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery.  Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist.  Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery.  The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist.  Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter.  Repeat angiograms were then performed.  Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein.  A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter.  An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein.  Once stable device was confirmed, the device was released from the delivery catheter.  The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein.  A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%.  The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen.  Remaining saturations reflected complete admixture.  There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow.  Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending, descending pressures were similar and normal.  Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg.  The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1.  The pulmonary vascular resistance was elevated at 4.4 Woods units.  Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg.  Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation.  There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg.  There was an increase in arterial pressure.  The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared.  Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava.  There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient.  There was absence of contrast filling of the right middle and right upper pulmonary artery.  Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow.  Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES:  ,1.  Asplenia syndrome.,2.  Dextrocardia bilateral superior vena cava.,3.  Atrioventricular septal defect.,4.  Total anomalous pulmonary venous return to the right-sided atrium.,5.  Double outlet right ventricle with malposed great vessels.,6.  Severe pulmonary stenosis.,7.  Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Bilateral bidirectional Glenn shunt.,3.  Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES:  ,1.  Obstructed right caval pulmonary anastomosis.,2.  Obstructed right proximal pulmonary artery.,3.  Venovenous collateral vessel.,CURRENT INTERVENTION:  ,1.  Balloon dilation of the right superior vena cava and stent implantation.,2.  Balloon dilation of the proximal right pulmonary artery, stent implantation.,3.  Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference.  A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion.  The patient will be maintained on anticoagulant medications of aspirin and Plavix.  Further cardiology care will be directed by Dr. X.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "repeat catheterization",
        "period_text": "in 3 months",
        "period_date": "2025-04-15",
        "action_char_start": 10752,
        "action_char_end": 10774,
        "time_char_start": 10790,
        "time_char_end": 10801,
        "in_closed_set": false,
        "coverage_note": "out_of_ontology"
      },
      {
        "action": null,
        "action_verbatim": "aspirin and Plavix",
        "period_text": null,
        "period_date": null,
        "action_char_start": 10957,
        "action_char_end": 10975,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      }
    ]
  },
  {
    "note_id": 1453,
    "specialty": "SOAP / Chart / Progress Notes",
    "sample_name": "Acne - SOAP",
    "visit_date_assumed": "2025-01-15",
    "transcription": "SUBJECTIVE:,  The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004.  She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back.  On examination, this is a flaring of her acne with small folliculitis lesions.  The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also.  She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc.  The patient is married.  She is a secretary.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  She has hay fever, eczema, sinus, and hives.  She has no melanoma or skin cancers or psoriasis.  Her mother had oral cancer.  The patient is a nonsmoker.  No blood tests.  Had some sunburn in the past.  She is on benzoyl peroxide and Daypro.,CURRENT MEDICATIONS:,  Lexapro, Effexor, Ditropan, aspirin, vitamins.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  She has a couple of acne lesions, one on her face and neck but there are a lot of small folliculitis-like lesions on her abdomen, chest, and back.,IMPRESSION:,  Acne with folliculitis.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Continue the amoxicillin 500 mg two at bedtime.,3.  Add Septra DS every morning with extra water.,4.  Continue the Tazorac cream 0.1; it is okay to use on back and chest also.,5.  Referred to ABC clinic for an aesthetic consult.  Return in two months for followup evaluation of her acne.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "amoxicillin 500 mg",
        "period_text": null,
        "period_date": null,
        "action_char_start": 396,
        "action_char_end": 414,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "Septra DS",
        "period_text": null,
        "period_date": null,
        "action_char_start": 1512,
        "action_char_end": 1521,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "Tazorac cream 0.1",
        "period_text": null,
        "period_date": null,
        "action_char_start": 432,
        "action_char_end": 449,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": null,
        "action_verbatim": "Referred to ABC clinic for an aesthetic consult",
        "period_text": null,
        "period_date": null,
        "action_char_start": 1636,
        "action_char_end": 1683,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "referral"
      },
      {
        "action": null,
        "action_verbatim": "Return",
        "period_text": "in two months",
        "period_date": "2025-03-15",
        "action_char_start": 1686,
        "action_char_end": 1692,
        "time_char_start": 1693,
        "time_char_end": 1706,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      }
    ]
  },
  {
    "note_id": 3310,
    "specialty": "General Medicine",
    "sample_name": "Gen Med Progress Note - 4",
    "visit_date_assumed": "2025-01-15",
    "transcription": "SUBJECTIVE:,  The patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf.  She describes her dizziness as both vertigo and lightheadedness.  She does not have a headache at present but has some intermittent headaches, neck pains, and generalized myalgias.  She has noticed a few more bruises on her legs.  No fever or chills with slight cough.  She has had more chest pains but not at present.  She does have a little bit of nausea but no vomiting or diarrhea.  She complains of some left shoulder tenderness and discomfort.  She reports her blood sugar today after lunch was 155.,CURRENT MEDICATIONS:,  She is currently on her nystatin ointment to her lips q.i.d. p.r.n.  She is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her Bactroban ointment t.i.d. p.r.n. to her bug bites on her legs.  Her other meds remain as per the dictation of 07/30/2004 with the exception of her Klonopin dose being 4 mg in a.m. and 6 mg at h.s. instead of what the psychiatrist had recommended which should be 6 mg and 8 mg.,ALLERGIES: , Sulfa, erythromycin, Macrodantin, and tramadol.,OBJECTIVE:,General:  She is a well-developed, well-nourished, obese female in no acute distress.,Vital Signs:  Her age is 55.  Temperature:  98.2.  Blood pressure:  110/70.  Pulse:  72.  Weight:  174 pounds.,HEENT:  Head was normocephalic.  Throat:  Clear.  TMs clear.,Neck:  Supple without adenopathy.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.,Extremities:  Trace of ankle edema but no calf tenderness x 2 in lower extremities is noted.  Her shoulders have full range of motion.  She has minimal tenderness to the left shoulder anteriorly.,Skin:  There is bit of an erythematous rash to the left wrist which seems to be clearing with triamcinolone and her rash around her lips seems to be clearing nicely with her nystatin.,ASSESSMENT:,1.  Headaches.,2.  Dizziness.,3.  Atypical chest pains.,4.  Chronic renal failure.,5.  Type II diabetes.,6.  Myalgias.,7.  Severe anxiety (affect is still quite anxious.),PLAN:,  I strongly encouraged her to increase her Klonopin to what the psychiatrist recommended, which should be 6 mg in the a.m. and 8 mg in the p.m.  I sent her to lab for CPK due to her myalgias and pro-time for monitoring her Coumadin.  Recheck in one week.  I think her dizziness is multifactorial and due to enlarged part of her anxiety.  I do note that she does have a few new bruises on her extremities, which is likely due to her Coumadin.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "increase her Klonopin",
        "period_text": null,
        "period_date": null,
        "action_char_start": 2179,
        "action_char_end": 2200,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      },
      {
        "action": "Blood Test",
        "action_verbatim": "CPK due to her myalgias and pro-time",
        "period_text": null,
        "period_date": null,
        "action_char_start": 2316,
        "action_char_end": 2352,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": true,
        "coverage_note": "no_time"
      },
      {
        "action": null,
        "action_verbatim": "Recheck",
        "period_text": "in one week",
        "period_date": "2025-01-22",
        "action_char_start": 2383,
        "action_char_end": 2390,
        "time_char_start": 2391,
        "time_char_end": 2402,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      }
    ]
  },
  {
    "note_id": 749,
    "specialty": "Surgery",
    "sample_name": "Heart Catheterization, Ventriculography, & Angiography - 10",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL:  ,The patient was brought to the Catheterization Laboratory.  After informed consent, he was medicated with Versed and fentanyl.  The right groin was prepped and draped, and infiltrated with 2% Xylocaine.  Percutaneously, #6-French arterial sheath was placed.  Selective native left and right coronary angiography was performed followed by left ventricular angiography.  The patient had a totally occluded right coronary.  We initially started with a JR4 guide.  We were able to a sport wire through the total occlusion and saw a very tight stenosis.  We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated.  We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out.  We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion.  We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection.  That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip.  The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire.  We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres.  Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment.  We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres.  Final angiography showed resolution of the dissection.  We could see a little staining extrinsic to the stent.  No perforation and excellent flow.  During the intervention, we did give a bolus and drip of Angiomax.  At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix.  We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop.  We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:,  Left main coronary is normal.  Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal.  The diagonal does appear to have about 50% osteal stenosis.  There is a lot of plaquing further down the diagonal, but good flow.  The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch.  Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel.  The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease.  Some mild collaterals to the right were seen.  Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin.  After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve.  Following the balloon angioplasty, we established good flow down the distal vessel.  We still had about residual 70% stenosis.  When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection.  We re-dilated and then deployed.  Repeat angiography now did show some hang up off dye distally.  We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus.  After deploying the stent, we had total resolution of the original lesion.  We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA.  The posterolateral branch appeared to be occluded in its mid portion.  We got a wire through and dilated this.  We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent.  Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent.  There were no filling defects in the stent and excellent flow.  The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection.  Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.",
    "follow_up_items": []
  },
  {
    "note_id": 2217,
    "specialty": "Orthopedic",
    "sample_name": "Hardware Removal - Elbow",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:,  Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia.  The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET:  ,There is no tourniquet time.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,No intraoperative complications.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture.  He underwent screw compression for the fracture in October 2007.  The fracture has subsequently healed and the patient presents for hardware removal.  The risks and benefits of surgery were discussed.  The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion.  All questions were answered and the family agreed to the above plan.,PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in standard surgical fashion.  Using his previous incision, dissection was carried down through the screw.  A guide wire was placed inside the screw and the screw was removed without incident.  The patient had an extension lag of about 15 to 20 degrees.  Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex.  The washer was also removed without incident.  Wound was then irrigated and closed using #2-0 Vicryl and #4-0 Monocryl.  Wound was injected with 0.25% Marcaine.  The wound was then dressed with Steri-Strips, Xeroform, 4 x4 and bias.  The patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,DISCHARGE NOTE: , The patient will be discharged on date of surgery.  He is to follow up in one week's time for a wound check.  This can be done at his primary care physician's office.  The patient should keep his postop dressing for about 4 to 5 days.  He may then wet the wound, but not scrub it.  The patient may resume regular activities in about 2 weeks.  The patient was given Tylenol with Codeine 10 mL p.o. every 3 to 4 hours p.r.n.",
    "follow_up_items": [
      {
        "action": "Orthopedic Consult",
        "action_verbatim": "follow up",
        "period_text": "in one week's time",
        "period_date": null,
        "action_char_start": 2003,
        "action_char_end": 2012,
        "time_char_start": 2013,
        "time_char_end": 2031,
        "in_closed_set": true,
        "coverage_note": "in_set"
      },
      {
        "action": null,
        "action_verbatim": "resume regular activities",
        "period_text": "in about 2 weeks",
        "period_date": "2025-01-29",
        "action_char_start": 2240,
        "action_char_end": 2265,
        "time_char_start": 2266,
        "time_char_end": 2282,
        "in_closed_set": false,
        "coverage_note": "self_care"
      }
    ]
  },
  {
    "note_id": 1955,
    "specialty": "Pain Management",
    "sample_name": "Transforaminal Epidural Steroid Injection",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PROCEDURE: , Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.,PATIENT PROFILE: , This is a 44-year-old female.  The patient reports greatly increasing pain over the past several weeks.  In addition, the patient has associated radicular symptoms of aching, radiating to the L3 dermatome distribution and L4 dermatome distribution.  She is status post posterior fusion and lumbar decompression within the past several years.  Due to the nature of the patient's persistent pain, epidural steroid injection is recommended.  The alternatives, benefits, and risks were discussed with the patient.  The patient verbalized understanding of the risks as well as the alternatives and wished to proceed with the procedure.  A signed and witnessed informed consent was placed on the chart.,PRE-OP DIAGNOSIS:,  Left leg pain, Left leg weakness, Left L3-4 radicular pain, Left L4-5 radicular pain, Lumbar spondylosis.,POST-OP DIAGNOSIS:,  Left leg pain, Left leg weakness, Left L3-4 radicular pain, Left, L4-5 radicular pain, Lumbar spondylosis.,ANESTHESIA:,  Midazolam 2 mg IV Fentanyl 50 mcg IV.,FINDINGS:,PAIN MANAGEMENT:,  The patient reports greatly increasing pain over the past several weeks.  The patient now rates pain as 8/10.  The reported pain is at L3-4 and L4-5.,DESCRIPTION OF PROCEDURE:,  The patient was placed in the prone position on the radiolucent operating table.  The lumbar area was prepped and draped in the appropriate sterile fashion.  The left L3-L4 level was identified for a transforaminal epidural injection and the overlying skin and subcutaneous tissue were anesthetized.  A 22 gauge 3.5 inch B-bevel spinal needle was passed through the skin wheal and advanced in a ventral direction until the tip of the needle was properly placed in the left superior posterior intervertebral foramen as confirmed by AP and lateral fluoroscopic views.  No blood was aspirated.  There was no CSF flow.  Following negative aspiration, 1 mL Isovue-M200 was injected to produce the epidurogram.  There was appropriate needle placement and no intravascular or intrathecal flow.  1 mL of a 40 mg/mL solution of Kenalog and 1 mL of 1% Lidocaine was injected.,Attention was then turned to the next injection.  The lumbar area was prepped and draped in the appropriate sterile fashion.  The left L4-L5 level was identified for a transforaminal epidural injection and a skin wheal was made at the spinal needle entry site.  A 22 gauge 3.5 inch spinal needle was passed through the skin wheal and advanced in a ventral direction until the tip of the needle was properly placed in the left superior posterior intervertebral foramen as confirmed by AP and lateral fluoroscopic views.  No blood was aspirated.  There was no CSF flow.  Following negative aspiration 1 mL Isovue-M200 was injected to produce the epidurogram.  There was appropriate needle placement and no intravascular or intrathecal flow.  1 mL of a 40 mg/mL solution of Kenalog and 1 mL of 1% Lidocaine was injected.  The patient tolerated the procedure well.,DRAINS / DRESSING:,  Applied sterile dressing including BAND-AID.,PATIENT TO RECOVERY ROOM: , The patient tolerated the procedure well, and was brought to the recovery room in excellent condition.,COMPLICATIONS: , No immediate complications,DISCHARGE ORDERS:,DISPOSITION: , Discharge patient to home today.,ACTIVITY: , Patient may resume normal activity level in 1 day.,FOLLOW-UP: , Appointment to Surgeon's Office in 2 weeks,CPT4 CODE(S):,64483 LT, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level.,64484 LT, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure).,76005, Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction.,ICD9 CODE(S):,724.4  Thoracic or lumbosacral neuritis or radiculitis.,721.3  Lumbosacral spondylosis without myelopathy.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "Appointment to Surgeon's Office",
        "period_text": "in 2 weeks",
        "period_date": "2025-01-29",
        "action_char_start": 3523,
        "action_char_end": 3554,
        "time_char_start": 3555,
        "time_char_end": 3565,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      },
      {
        "action": null,
        "action_verbatim": "resume normal activity level",
        "period_text": "in 1 day",
        "period_date": "2025-01-16",
        "action_char_start": 3471,
        "action_char_end": 3499,
        "time_char_start": 3500,
        "time_char_end": 3508,
        "in_closed_set": false,
        "coverage_note": "self_care"
      }
    ]
  },
  {
    "note_id": 2180,
    "specialty": "Orthopedic",
    "sample_name": "Kyphosis",
    "visit_date_assumed": "2025-01-15",
    "transcription": "REASON FOR VISIT: , Kyphosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis.  The patient has a family history in a maternal aunt and grandfather of kyphosis.  She was noted by her parents to have round back posture.  They have previously seen another orthopedist who recommended observation at this time.  She is here for a second opinion in regards to kyphosis.  The patient denies any pain in her back or any numbness, tingling, or weakness in her upper or lower extremities.  No problems with her bowels or bladder.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Bilateral pinning of her ears.,SOCIAL HISTORY:  ,She is currently an eighth grader at Middle School and is interested in basketball.  She lives with both of her parents and has a 9-year-old brother.  She had menarche beginning in September.,FAMILY HISTORY:  ,Of kyphosis in great grandmother and second cousin.,REVIEW OF SYSTEMS: , She is in her usual state of health and is negative except otherwise as mentioned in the history of present illness.,MEDICATIONS: , She is currently on Zyrtec, Flonase, and Ceftin for an ear infection.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, she is alert, oriented, and in no acute distress standing 63 inches tall.  In regards to her back, her skin is intact with no rashes, lesions, and/or no dimpling or hair spots.  No cafe au lait spots.  She is not tender to palpation from her occiput to her sacrum.  There is no evidence of paraspinal muscle spasm.  On forward bending, there is a mild kyphosis.  She is not able to touch her toes indicating her hamstring tightness.  She has a full 5 out of 5 in all muscle groups.  Her lower extremities including iliopsoas, quadriceps, gastroc-soleus, tibialis anterior, and extensor hallucis longus.  Her sensation intact to light touch in L1 through L2 dermatomal distributions.  She has symmetric limb lengths as well bilaterally from both the coronal and sagittal planes.,X-rays today included PA and lateral sclerosis series.  She has approximately 46 degree kyphosis.,ASSESSMENT: , Kyphosis.,PLANS:  ,The patient's kyphosis is quite mild.  While this is likely in the upper limits of normal or just it is normal for an adolescent and still within normal range as would be expected return at home.  At this time, three options were discussed with the parents including observation, physical therapy, and bracing.  At this juncture, given that she has continued to grow, they are Risser 0.  She may benefit from continued observation with physical therapy, bracing would be a more aggressive option certainly that thing would be lost with following at this time.  As such, she was given a prescription for physical therapy for extension based strengthening exercises, flexibility range of motion exercises, postural training with no forward bending.  We will see her back in 3 months' time for repeat radiographs at that time including PA and lateral standing of scoliosis series.  Should she show evidence of continued progression of her kyphotic deformity, discussions of bracing would be held at time.  We will see her back in 3 months' time for repeat evaluation.",
    "follow_up_items": [
      {
        "action": "X-Ray",
        "action_verbatim": "repeat radiographs",
        "period_text": "in 3 months' time",
        "period_date": null,
        "action_char_start": 2946,
        "action_char_end": 2964,
        "time_char_start": 2924,
        "time_char_end": 2941,
        "in_closed_set": true,
        "coverage_note": "in_set"
      },
      {
        "action": "Physical Therapy",
        "action_verbatim": "physical therapy for extension based strengthening exercises",
        "period_text": null,
        "period_date": null,
        "action_char_start": 2758,
        "action_char_end": 2818,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": true,
        "coverage_note": "no_time"
      }
    ]
  },
  {
    "note_id": 3301,
    "specialty": "General Medicine",
    "sample_name": "Gen Med SOAP - 2",
    "visit_date_assumed": "2025-01-15",
    "transcription": "SUBJECTIVE:,  Overall, she has been doing well.  Her blood sugars have usually been less than or equal to 135 by home glucose monitoring.  Her fasting blood sugar today is 120 by our Accu-Chek.  She is exercising three times per week.  Review of systems is otherwise unremarkable. ,OBJECTIVE:,  Her blood pressure is 110/60.  Other vitals are stable.  HEENT:  Unremarkable.  Neck:  Unremarkable.  Lungs:  Clear.  Heart:  Regular.  Abdomen:  Unchanged.  Extremities:  Unchanged.  Neurologic:  Unchanged. ,ASSESSMENT:,  ,1.  NIDDM with improved control. ,2.  Hypertension. ,3.  Coronary artery disease status post coronary artery bypass graft. ,4.  Degenerative arthritis. ,5.  Hyperlipidemia. ,6.  Hyperuricemia. ,7.  Renal azotemia. ,8.  Anemia. ,9.  Fibroglandular breasts. ,PLAN:,  We will get follow-up labs today.  We will continue with current medications and treatment.  We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY.  The patient is advised to proceed with previous recommendations.  She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed.",
    "follow_up_items": [
      {
        "action": "Blood Test",
        "action_verbatim": "follow-up labs",
        "period_text": null,
        "period_date": null,
        "action_char_start": 796,
        "action_char_end": 810,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": true,
        "coverage_note": "no_time"
      },
      {
        "action": null,
        "action_verbatim": "follow-up mammogram",
        "period_text": "in six months",
        "period_date": "2025-07-15",
        "action_char_start": 899,
        "action_char_end": 918,
        "time_char_start": 953,
        "time_char_end": 966,
        "in_closed_set": false,
        "coverage_note": "referral"
      },
      {
        "action": null,
        "action_verbatim": "follow-up with Ophthalmology and Podiatry for diabetic evaluation",
        "period_text": null,
        "period_date": null,
        "action_char_start": 1089,
        "action_char_end": 1154,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "referral"
      }
    ]
  },
  {
    "note_id": 317,
    "specialty": "Surgery",
    "sample_name": "Suction, Dilation, & Curettage - 1",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PREOPERATIVE DIAGNOSIS: ,Incomplete abortion.,POSTOPERATIVE DIAGNOSIS: ,Incomplete abortion.,PROCEDURE PERFORMED:, Suction dilation and curettage.,ANESTHESIA:  ,General and nonendotracheal by Dr. X.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,SPECIMENS: , Endometrial curettings.,DRAINS: , None.,FINDINGS:  ,On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  There was a large amount of tissue obtained on the procedure.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina.  The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed.  A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed.  Two passes were made with the suction curettage.  Next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus.  After the procedure, the vulsellum tenaculum was removed.  The cervix was seemed to be hemostatic.  The weighted speculum was removed.  The patient was given 0.25 mg of Methergine IM approximately half-way through the procedure.  After the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size.  It is now approximately eight to ten-week size.  The patient was taken from the operating room in stable condition after she was cleaned.  She will be discharged on today.  She was given Methergine, Motrin, and doxycycline for her postoperative care.  She will follow-up in one week in the office.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "follow-up",
        "period_text": "in one week",
        "period_date": "2025-01-22",
        "action_char_start": 2113,
        "action_char_end": 2122,
        "time_char_start": 2123,
        "time_char_end": 2134,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      },
      {
        "action": null,
        "action_verbatim": "Methergine, Motrin, and doxycycline",
        "period_text": null,
        "period_date": null,
        "action_char_start": 2039,
        "action_char_end": 2074,
        "time_char_start": -1,
        "time_char_end": -1,
        "in_closed_set": false,
        "coverage_note": "med_change"
      }
    ]
  },
  {
    "note_id": 623,
    "specialty": "Surgery",
    "sample_name": "Laparoscopy",
    "visit_date_assumed": "2025-01-15",
    "transcription": "PREOPERATIVE DIAGNOSIS:,  Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Pelvic endometriosis.,3.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Laparoscopy.,2.  Harmonic scalpel ablation of endometriosis.,3.  Lysis of adhesions.,4.  Cervical dilation.,ANESTHESIA:  ,General.,SPECIMEN:  ,Peritoneal biopsy.,ESTIMATED BLOOD LOSS:,  Scant.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small, anteverted, and freely mobile uterus with no adnexal masses.  Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.  There are adhesions involving the right ovary to the anterior abdominal wall and the bowel.  There are also adhesions from the omentum to the anterior abdominal wall near the liver.  The uterus and ovaries appear within normal limits other than the adhesions.  The left fallopian tube grossly appeared within normal limits.  The right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized.  There was a large area of endometriosis, approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul-de-sac.  There was also vesicular appearing endometriosis lesion in the posterior cul-de-sac.,PROCEDURE:  ,The patient was taken in the operating room and generalized anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  After exam under anesthetic, weighted speculum was placed in the vagina.  The anterior lip of the cervix was grasped with vulsellum tenaculum.  The uterus was sounded and then was serially dilated with Hank dilators to a size 10 Hank, then the uterine manipulator was inserted and attached to the anterior lip of the cervix.  At this point, the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen.  An approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife.  The superior aspect of the umbilicus was grasped with a towel clamp.  The abdomen was tented up and a Veress needle inserted through this incision.  When the Veress needle was felt to be in place, deep position was checked by placing saline in the needle.  This was seen to freely drop in the abdomen so it was connected to CO2 gas.  Again, this was started at the lowest setting, was seen to flow freely, so it was advanced to the high setting.  The abdomen was then insufflated to an adequate distention.  Once an adequate distention was reached, the CO2 gas was disconnected.  The Veress needle was removed and a size #11 step trocar was placed.  Next, the laparoscope was inserted through this port.  The medial port was connected to CO2 gas.  Next, a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis.  Through this, a Veress needle was inserted followed by size #5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size #5 trocar was also placed.  Next, a grasper was placed through the suprapubic port.  This was used to grasp the bowel that was adhesed to the right ovary and the Harmonic scalpel was then used to lyse these adhesions.  Bowel was carefully examined afterwards and no injuries or bleeding were seen.  Next, the adhesions touching the right ovary and anterior abdominal wall were lysed with the Harmonic scalpel and this was done without difficulty.  There was a small amount of bleeding from the anterior abdominal wall peritoneum.  This was ablated with the Harmonic scalpel.  The Harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul-de-sac.  Both of these areas were seen to be hemostatic.  Next, a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul-de-sac.  This was sent to pathology.  Next, the pelvis was copiously irrigated with the Nezhat dorsi suction irrigator and the irrigator was removed.  It was seen to be completely hemostatic.  Next, the two size #5 ports were removed under direct visualization.  The camera was removed.  The abdomen was desufflated.  The size #11 introducer was replaced and the #11 port was removed.,Next, all the ports were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion.  The incisions were dressed with Steri-Strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with Darvocet for pain and she will follow-up in one week in the clinic for pathology results and to have a postoperative check.",
    "follow_up_items": [
      {
        "action": null,
        "action_verbatim": "follow-up",
        "period_text": "in one week",
        "period_date": "2025-01-22",
        "action_char_start": 4689,
        "action_char_end": 4698,
        "time_char_start": 4699,
        "time_char_end": 4710,
        "in_closed_set": false,
        "coverage_note": "generic_followup"
      }
    ]
  }
]