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[ { "content": "A 13-year-old girl was referred to our department with dull pain in the right knee while in motion, which she had noticed approximately one", "role": "user" }, { "content": " month before her initial visit. There was no pain at <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 31-year-old man with intellectual disability and cerebral palsy presented to the emergency department with recurrent esophageal food impaction. He had no medical history of asthma or food-related allergies. His family history and social history were otherwise unremarkable. He was allergic to phenobarbital medication with no clear details available about the allergic reaction. Physical examination including vital signs and abdominal and cardiorespiratory examination was within normal limits. His neurologic examination was notable for his inability to communicate, follow commands, or ambulate. The basic laboratory investigations including complete blood count (CBC), comprehensive metabolic panel (CMP), and coagulation profile were within normal limits except mild chronic microcytosis. There was no laboratory evidence of peripheral eosinophilia. The Ig", "role": "user" }, { "content": " E-mediated allergic test was unremarkable. He underwent esophagogastroduodenoscopy (EGD) with upper and distal esophagus biopsy. He had an increased eosinophilic count of >15/hpf () in both biopsies and was diagnosed with eosinophilic esophagitis. He was initially managed with the proton pump inhibitor with persistent esophageal eosinophilia on repeat endoscopy. He was managed with oral 1 mg of budesonide (0.5 mg per ml repulse) two times a day for 6 weeks. The viscous solution was mixed with Splenda®. The patient's mother reported the compliance to the regimen, and he swallowed the viscous solution with no nausea or vomiting. He continued to have elevated eosinophils on repeat endoscopy despite steroid and elimination diet though the eosinophilic count was significantly decreased compared to previous esophageal biopsy (). He was on oral budesonide during the index presentation to ER and had impaction of a respule. In recent hospital admission, he presented to the emergency department with esophageal foreign body impaction and underwent emergent endoscopy with retrieval of foreign bodies. During endoscopy, he was noted to have normal-appearing esophageal mucosa, proximal esophageal dilatation with extrinsic compression at the level of upper esophagus. To further delineate the cause of recurrent esophageal impaction, computed tomography (CT) scan of the neck and <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 45-year-old Chinese man involved in a road traffic accid", "role": "user" }, { "content": " ent was admitted to the emergency department presenting with a Glasgow Coma <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 62-year-old man with a history of hypertension and dyslipidemia became aware of visual field impairment and right upper limb weakness. 5 months later, he underwent a check-up at the hospital ophthalmology clinic, where he was diagnosed with right homonymous hemianopsia. Computed tomography (CT) showed an intracranial mass lesion, for which he was referred to the neurosurgical department of the same hospital. At that time, he had symptoms of the right homonymous hemianopsia and weakness of the right upper limb (manual motor test: 4/5).\nCT imaging revealed a multilobular heterogeneous density mass with a diameter of 38 mm × 33 mm × 23 mm, which compressed the ipsilateral basal ganglia. CT angiography showed unremarkable enhancement of the mass lesion. Head magnetic resonance (MR) T1-weighted imaging showed a heterogenous mixed intensity mass buried in the left basal ganglia, and compression of the optic nerve on the contralateral side. MR T2-weighted images showed findings suggestive of partial aneurysm wall hemorrhage, with no remarkable perifocal edema in the vicinity of the dome. Contrast-enhanced MR imaging (MRI) demonstrated poor contrast enhancement of the aneurysm wall which indicates little involvement of the vasa vasorum []. Digital subtraction angiography (DSA) showed small contrast depiction at the vicinity of the neck of the aneurysm with a diameter of 6.5 mm × 6.5 mm × 4.5 mm at the terminal part of the left internal carotid artery (ICA) []. Perforators originating from the vicinity of the aneurysmal neck were depicted and the terminal part of the ICA. The patient was diagnosed as having a symptomatic, giant, partially thrombosed left ICA aneurysm compressing the visual pathway and the posterior limb of the internal capsule.\nIn such cases, the treatment strategy of direct surgical decompression of the aneu", "role": "user" }, { "content": " rysm can be expected to immediately improve the symptoms caused by the mass effect. However, the procedure is associated with difficulty in securing the perforators <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 34 year old female patient reported to Department of Oral Medicine and Radiology, with a chief complaint of swelling of the lower jaw since six years. She stated that a small swelling on the left side of jaw was noticed six years ago, measuring about 1cm in diameter, which gradually increased to the present size, involving both sides of the face. There were no subjective symptoms, except for difficulty in chewing food.\nGross facial asymmetry was noticed due to a swelling involving the middle and lower one third region of the face []. Bilaterally fullness of the cheeks and lower lip with obliteration of the mentolabial sulcus and nasolabial fold was noticed. A well demarcated swelling was noticed over the left cheek region and a diffuse swelling over the right side, which extended from the left ramus of the mandible to the right body of the mandible with obliteration of inferior border of the mandible. Swelling on the left side was roughly ovoid in shape, measuring about 8 × 6 × 5 cm[]. Skin over the swelling was stretched. On palpation the swelling is hard in consistency, lobulated and nontender; with no accompanying cervical lymphadenopathy.\nOn intraoral examination [], a diffuse swelling was seen extending from the left to right retromolar region. Bilaterally, vestibular obliteration was noticed due to buccal labial and lingual cortical plate expansion with normal appearing mucosa. Swelling was hard, lobulated and nontender. Correlating the history and clinical findings, a provisional diagnosis of benign fibro-osseous lesion of mandible was given and differential diagnosis of fibrous dysplasia, ossifying/cementifying fibroma and central giant cell granuloma (non- aggressive lesion) was given. Patient was further subjected to hematological, radiological and histopathological investigations. Routine hematological examination, serum protein, calcium, phosphorus and alkaline phophatase levels were estimated and the values obtained were within the normal range.\nPanoramic radiograph ", "role": "user" }, { "content": " [] revealed <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 10-year-old female patient reported to a private dental clinic with a chief complaint of a slowly growing, painless swelling of 6 months’ duration in the maxillary anterior region. On general examination, she was apparently healthy. Medical and family history did not reveal anything of significance. On extraoral examination, no abnormalities were detected.\nIntraoral examination revealed a solitary firm nontender enlargement (1×0.5 cm) of marginal and attached gingiva covering the cervical third of the tooth in relation to a palatally displaced 21 (). It was a slowly growing swelling. The colour of the lesion was pale pi", "role": "user" }, { "content": " nk. The lesion was asymptomatic with no pain, bleeding on <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 63-year-old female patient presented with reduced vision in her right eye. She reported experiencing sudden-onset pain, loss of vision, and redness in her right eye 7 years earlier, but did not seek medical treatment at that time. She had no history of ocular trauma or surgery. Best corrected visual acuity (BCVA) in her right eye was light perception and intraocular pressure was 18 mmHg. Anterior segment examination revealed hypermature cataract. The iris stroma showed diffuse atrophy and appeared hypochromic. Ultrasonography demonstrated retinal attachment. Cataract surgery was recommended, but the patient refused.\nAt 1-year follow-up examination, the patient stated that her vision had improved. BCVA was 20/25 in the right eye (with +12 D correction) and 20/20 in the left eye. Although her right eye appeared aphakic on anterior segment examination, no surgical scar or signs of trauma were detected. The cornea was clear and the conjunctiva appeared normal. Despite the hyperchromic appearance and stroma atrophy of the iris, there were no findings suggestive of inflammation (keratic precipitates in the corneal endothelium, posterior synechia, or anterior chamber inflammatory cells). The left eye appeared normal (). Intraocular pressure was 18 mmHg in the right eye and 16 mmHg in the left eye. The areas that could be visualized in fundus examination were normal. A peripheral retinal scan was done to see the crystalline lens. An ideal evaluation could not be performed because the patient had sunken eyes and incomplete pupil dilation. However, no crystalline lens material was observed in the visualized areas. The absence of crystalline lens material in peripheral retinal examination raised the suspicion of crystalline lens subluxation behind the iris. Ultrasound biomicroscopy (UBM) was performed, but UBM images did not show any lens material behind the iris (). B-scan ultrasound revealed a hyperechoic appearance in the inferior peripheral retina suggesting luxation (). Based on these findings, the pati", "role": "user" }, { "content": " ent was <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "This is a case of a 68-year-old female presented to the clinic ", "role": "user" }, { "content": " for a 2-month history of <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 51-year-old female with a history of rheumatoid arthritis and a 10.5-pack-year smoking history presented with an aspergilloma in her right lung. After failing medical management, she was treated with a right pneumonectomy at an outside institution. This was complicated by BPF and empyema of the pneumonectomy cavity. She underwent two additional thoracotomies requiring rib resection, and placement of serratus anterior and later latissimus dorsi flap to close the fistula. Seven months following her last operation, she presented to us with stridor, persistent cough, and dysphagia, concerning for postpneumonectomy syndrome. Review of last computed tomography (CT) imaging from three months after the pneumonectomy revealed a multiloculated pleural space, with air fluid levels in the pneumonectomy cavity. An updated CT scan showed interval progressive rightward mediastinal shift with nearly complete obliteration of the pneumonectomy cavity by the heart (Fig. ). A bronchoscopy was performed, which demonstrated narrowing of the left mainstem bronchus (Fig. a) and stenosis of the lower lobe bronchial orifice due to external compression of the airways. Results of a previous complex right-sided BPF with two areas of disrupted bronchial staple line were noted (Fig. b).\nThe patient elected to proceed with operative correction of her postpneumonectomy syndrome. A thoracotomy in the fifth intercostal space was performed and dense adhesions in the chest with rotation of mediastinal structures were faced. Upon entering the pleural space, a small loculated serous fluid collection was encountered. To rule out an infected field, the pleural rind and fluid samples were sent for intraoperative gram stains, which returned negative. Cultures were also submitted. The mediastinum was mobilized from the chest wall, taking care to avoid damage to the muscle flaps, which had previously sealed the BPF. As a result, only the mid and inferior portion of the mediastinum was mobilized. A saline immersion test was performed t", "role": "user" }, { "content": " o ensure the integrity of the muscle <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 51-year-old woman presented with a massive painless lump on ", "role": "user" }, { "content": " both of her thighs that had been enlarging for the past 6 months. The patient denied any history of trauma, manipulation, or injection around the lump before. She was otherwise healthy despite her lumps. However, she had a history of lymph node tuberculosis on her neck about 25 years before and underwent tuberculosis chemotherapy regiment for about six months.\nOn the local physical examination, we found a painless non-mobile distention on her gluteal and upper femoral region bilaterally with some fluctuation and cystic consistency on palpation of the mass. The initial largest diameter of her thigh was 60 cm on the left and 45 cm on the right. There was no signs of inflammation, sinus or fistula around her thighs and buttock, or any remarkable signs on physical examinations (). Laboratory examinations however, showed elevated level of ESR and CRP. Mantoux test were inconclusive due to previous infection of tuberculosis. Radiological examination showed no signs of abnormality besides the expanding soft tissue shadow especially on her left femur region.\nMRI examinations were then performed over the lumbosacral and pelvis region. Sagittal T2 weighted MR images of the sacrum showed destruction on anterior lower sacral segments, with hyperintense anterior lesion and presacral abscess. Axial T2 weighted images confirmed sacral body destruction and extension of the hyperintense lesion that involved the insertion of piriformis muscle (a and b).\nPelvic axial fat-suppressed (FS) T2 weighted images gave another extended view of the lesion, showing lateral extension of the lesion over the posterior ilium that also extended to superior and inferior filling the gluteal compartment beneath the gluteus maximus and tensor fascia lata (c). Involvement of the piriformis muscle and gluteus medius were confirmed at the coronal FS-T2 images of proximal femur, in which there was a hyperintese bony lesion at the tip of greater trochanter. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 30-year-old woman developed mesenteric ischemia due to catastrophic antiphospholipid syndrome, requiring a massive intestinal resection with end jejunostomy 45 cm from the Treitz angle and end ileostomy 7 cm from the ileocecal valve. The patient had the 4 criteria of catastrophic antiphospholipid syndrome: involvement of 3 or more organs, simultaneous development of manifestations, antiphospholipid antibodies, and histological confirmation of small vessel thrombosis [, ]. In this case, catastrophic antiphospholipid syndrome appeared to be induced by an active tuberculosis that was diagnosed and treated later. Over the next 2 months, the patient required TPN, anticoagulation, and specific treatment for pulmonary tuberculosis reactivation. Constant vomiting was attributed to hyperphagia, a common occurrence related to SBS []. Afterwards, she underwent surgery to restore intestinal continuity. Due to necrosis of the terminal ileum with only 4 cm of terminal ileum left, jejunoileal anastomosis at the ileocecal valve was practiced and STEP was performed as in the previous case, using 12 stapler cartridges to obtain a total length of small bowel of 90 cm (calculated length = 45 cm + [12 × 4.5 cm]). Cholecystectomy and gastrostomy were also performed. Postoperatively, the gastrostomy had a persistent output of 1,500 mL/day. Upper gastrointestinal series performed through gastrostomy showed a stop in the third portion of the duodenum. Magnetic resonance angiography confirmed the diagnosis of superior mesenteric artery syndrome with perivascular fibrosis and intravascular thrombus (Fig. ). Corticosteroid treatment was initiated and a feeding jejunostomy tube was placed endoscopically, with the catheter tip distal to the stenotic area. Subsequent improvement was observed over the next 2 weeks,", "role": "user" }, { "content": " with <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A male patient aged 73 years was admitted with two ulcers to his right lower leg and rest pain, which he attributed to a traumatic injury 8 weeks prior to presentation. He was known to have peripheral vascular occlusive disease with documented stenosis in both common iliac arteries (CIA), the left external iliac artery (EIA) and common femoral artery and occlusion of the right EIA.\nHis other relevant medical history includes a renal transplant, for which he takes regular prednisolone and azathioprine. He also had ischaemic heart disease with recent cardiac drug eluting stent insertion necessitating dual antiplatelet agent therapy and a coronary artery bypass graft in 1996.\nClinically he was aypyrexic with compromised circulation to his leg, which was pale but warm, and were absent of pulses on the affected side. There was a 1 cm wide ulcer located in the gaiter area, and a 3 cm wide ulcer located in the middle third of his lower leg posteriorly. Both lesions had a punched out appearance, with evident necrosis and no discharge or foul smell. He had a normal white cell count, a CRP count of 240 mg/L, potassium levels of 5.8 mmol/L and a creatinine level of 232 μmol/L.\nHis ankle brachial pressure index values were 0.23 on the right and 0.40 on the left. An arterial Doppler study showed no change in his occlusive disease, with patent, highly calcified vessels distally with poor flow. Doppler ultrasound studies of his transplanted kidney was normal.\nTo preserve renal function, a lower leg angiogram was performed using carbon dioxide. This showed an occluded right EIA and stenosed left CIA, with otherwise patent superficial femoral arteries bilaterally.\nWhile undergoing medical assessment for a right EIA endarterectomy and left EIA stenting, the ulcers progressed in size necessitating a surgical debridement. Tissue samples from the initial debridement were sent for histopathology and microbiology.\nDespite debridement to healthy", "role": "user" }, { "content": " tissue and skin, there was significant deterioration of the margins as well as new areas <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 67-year-old man with a body mass index of 45.3 kg/m2 presented with a large recurrent ventral hernia. He had undergone laparoscopic IPOM repair 2 years back at a peripheral centre and subsequently developed a mesh infection for which he underwent a laparotomy and mesh removal in the postoperative period. When he presented to us, he had a large ventral hernia with bowel and omentum as contents. The size of the defect was approximately 10 cm.\nAs the defect was very large and the patient was morbidly obese, we offered the patient the option of combined bariatric surgery with ventral hernia repair. After workup and discussion with the patient, we planned a laparoscopic sleeve gastrectomy along with a laparoendoscopic anterior component separation with an IPOM.\nThe patient lies supine with both arms abducted with a 10°–15° Trendelenburg position. Surgeon stands at the head end near the right shoulder, and camera assistant stands near the left shoulder. Pneumoperitoneum was created using Veress needle. A 10 mm port was placed in the subxiphoid position followed by two 5 mm working port in the midclavicular line on either side. The contents of the hernia were small bowel and omentum. There were extensive adhesions between the contents and the sac and adhesion were lysed to reduce the hernia contents completely. The size of the defect was assessed and it was found to be about 10 cm which could not be approximated without performing a component separation []. Thereafter, sleeve gastrectomy was performed by conventional 5 port technique (previously published) using a 38 French gastric calibration tube. Anterior component separation was then performed first on the right side, then on the left side.\nA 1.5 cm incision was made just below the costal margin at the anterior axillary line. Subcutaneous tissue was dissected to expose the external oblique aponeurosis. A small incision was made on the external o", "role": "user" }, { "content": " blique aponeurosis, and a 10 mm port <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 71-year-old male with a history of chronically", "role": "user" }, { "content": " implanted ICD (6 years) was initially admitted to electrophysiology (EP) suite <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 36-year-old patient was referred to a private genetic counseling service because, besides an extensive family history of cancer, she had a 2.0 cm lump detected in her right breast, as assessed by Magnetic Resonance Imaging, of Breast Imaging Reporting and Data System (BIRADS) category 4. The biopsy by fine needle aspiration showed a ductal proliferative breast lesion. The patient had a high risk for breast cancer and family history of cancer, with kindred diagnosed before the age of 50 years. The analysis of her pedigree showed an autosomal dominant disorder from her paternal side () with early onset cases of colon adenocarcinoma, gastric, lung, prostate and pancreas cancer.\nAccording to the ANS guideline, the patient did not meet the criteria to be tested for germline mutations because (i) she had no current or previous cancer diagnosis, (ii) she was not of Ashkenazi jewish origin, and (iii) there were no known mutations in her family. It is important to highlight that the patient was informed she was not the perfect index patient for family genetic counseling since she was not diagnosed with cancer; thus, her result was limited to individual genetic counseling, i.e., a negative result for presence of mutation would not mean the absence of mutation in her family.\nSince Brazil lacks a specific guideline to screen hereditary cancer, the worldwide applied United States National Comprehensive Cancer Network (NCCN) is routinely used. It comprises recommendations on the prevention, diagnosis, and management of maligna", "role": "user" }, { "content": " ncies across the continuum of care. The NCCN Guidelines incorporate real-time updates in keeping with the rapid advancements in <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The patient was a 51-year-old female, with a past medical history significant for heavy smoking for many years and recent liposuction of the abdomen and gluteal regions, who presented to the ED with a complaint of severe pain in the RLE. She reported having undergone the liposuction procedure the day before her presentation and she had been wearing a tight waist training corset since. The patient denied any trauma to her RLE or any ", "role": "user" }, { "content": " previous episodes of such symptoms. On presentation, she had a temperature of 97.6 °F, <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 40-year-old man came to the casualty with a thoracic bullet injury. At presentation, he had loss of power in both the lower limbs and dyspnea. The supine plain radiograph of the chest taken in the casualty revealed a bullet in the left hemithorax and diffuse-increased opacity of the left hemithorax. An axial CT scan of the dorsal spine revealed a fracture of the sixth dorsal vertebra with comminution of fragments and canal compromise (not shown). The bullet was seen to lie in the left pleural cavity and a left-sided pleural effusion was present. The patient was taken for orthopedic procedure including posterior fixation and retrieval of the bullet from the pleural cavity. Following the surgical procedures he was kept in intensive therapy unit where in the post-op days he was detected to have reduced air entry on the left side of the chest. Once oral feeding was started, leakage of food material through the intercostals tube was noted and an esophago-pleural communication was suspected. A contrast-enhanced computed tomography of the thorax was performed after giving oral iodinated nonionic contrast. Axial section of mediastinal window at the level of carina showed left hydropneumothorax and compression collapse of the left lung lower lobe. Orally administered iodinated contrast was seen to accumulate in the left pleural cavity, suggesting an esophago-pleural fistula. The iodinated contrast was seen to follow a long irregular track in the mediastinum communicating the mid-thoracic esophagus to the pleural cavity and running in close proximity to the left main bronchus []. Cervical esophagostomy, cervical esophageal exclusion, and feeding jejunostomy were performed as a therapeutic procedure. In the postoperative period he was detected to have a continued air leak and bronchoscopy was performed with the clinical diagnosis of a bronchopleural fistula. Bronchoscopy revealed a rent in the anterior wall of the left main bronchus (2 mm in diameter) []. Considering the general condi", "role": "user" }, { "content": " tion of the patient a bronchoscopic closure of the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The 83-year-old patient presented herself at a neurological emergency department with bilateral blindness and a history of severe headache, which she described the day before. An urgent computed tomography (CT) scan of the brain had been arranged, and a massive pituitary adenoma with hemorrhage was observed, and admission to the neurosurgical department immediately followed. When arriving at the hospital the hemodynamic parameters were stable (BP 130/90, 65 BPM); Glasgow coma score was 14/15. Her medical history included chronic renal failure (III°) as well as cardiovascular disease with hypertension, chronic atrial fibrillation, coronary heart disease with percutaneous transluminal coronary angioplasty, and stent. Therefore, dual oral anticoagulation with clopidogrel and acetylsalicylic acid was administered. Multiple electrode aggregometry did not detect effects of both anticoagulants. The neuro-ophthalmic examination revealed no perception of light in both eyes. Fundoscopy was normal without pallor of the optic nerves, no meningeal signs, and no overt clinical signs of hormone imbalance, but the measured pitu", "role": "user" }, { "content": " itary hormone profile had a slight elevated prolactin level and suppression of sex hormones and thyroid profile (Table ). The blood tests revealed normal electrolytes and infection parameters. A magnetic resonance imaging (MRI) demonstrated a large 22 mm x 18 mm x 15 mm enhancing hemorrhagic pituitary macroadenoma with suprasellar extension and compression of the optic chiasm (Figure ). Emergency surgery was indicated. A transsphenoidal approach was carried out under general anesthesia. The pituitary tumor was identified, though it was not characteristic of a hemorrhagic pituitary macroadenoma. The tumor was tough and yellow colored, and debulking with a sharp curettage was difficult. Acute hemorrhage ceased after resection of tumor. Dopamine agonist was not used due to the patient experiencing complete blindness. After decompression, the surgery was concluded. After a period of cardio-pulmonary stability in the ICU, the patient was extubated. In this case, the transsphenoidal decompression of the optic chiasm provided an improvement in both eyes. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "This was a case of a 23-year old G4 P3 A3 woman at a gestational age of 39 weeks in April, 2017 who was referred to the labour ward of the University of Calabar Teaching Hospital (UCTH), Calabar, Southern Nigeria, with a history of inability to deliver her baby after 5 days in labour prior to presentation. The patient had been managed in two different traditional birth attendant (TBA) homes. The second TBA recognized that the cause of prolonged labour was abnormal lie of the fetus and attempted to correct the lie by intrauterine manipulation through the vagina. This resulted in uterine rupture and subsequent evisceration of the intra-abdominal viscus through the vagina. The loop of the small intestine was initially mistaken for umbilical cord by the TBA who pulled several lengths of it through the vagina (). Following the failed attempt to deliver the baby and the woman's deteriorating clinical state, the patient was subsequently rushed to UCTH.\nAt UCTH, the patient was resuscitated. Parenteral broad spectrum antibiotics were administered. The extruded loops of bowel were wrapped in sterile guaze soaked with warm normal saline. A general surgeon was invited to take part in the management of the patient. The patient was immediately prepared and taken to theatre for emergency laparotomy.\nA midli", "role": "user" }, { "content": " ne incision was made to access the peritoneal cavity. Intra-operatively, a macerated female fetus was found in the uterine cavity. There was a left postero-lateral uterine wall tear extending from the mid portion to the posterior vaginal fornix. The loops of bowel extruded through this opening. The dead fetus was extracted. About 1,200 ml of blood in the peritoneal cavity was suctioned. Total abdominal hysterectomy was performed.\nThe whole intestines were thoroughly examined (Figures and ); about half the length of the intestine was devitalized and therefore, resected and an end-to-end anastomosis was done. The peritoneal <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 84-year-old Japanese woman was referred to our hospital with appetite loss and vomiting. She saw her family doctor three weeks previously, but was only diagnosed with appetite loss. A physical examination showed that her vitals were stable, but that she was dehydrated. Abdominal distention was observed, and palpa", "role": "user" }, { "content": " tion revealed <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 74-year-old male with past medical history of atrial fibrillation, hypertension, dyslipidemia, and benign prostatic hypertrophy presented to the emergency department with testicular swelling and pain for four days. Physical exam was notable for an abscess on the inner gluteal fold of the perineal region that was spontaneously draining serosanguinous output. His left hemi-scrotum appeared erythematous and indurated without overt signs of cellulitis. There was mild tenderness to palpation of the scrotal area although no crepitus was felt in the thighs or scrotum. He also endorsed blood-tinged drainage from the wound for several weeks. He was admitted for the management of his scrotal wound. He was evaluated by urology and general surgery who had low suspicion for Fournier’s gangrene. Medical records demonstrated several urological procedures for ureterolithiasis and nephrolithiasis in the few months prior to this admission. The procedures included a bilateral ureteroscopy with laser lithotripsy followed by stone removal, stricturotomy, and placement of ureteral stents to prevent the progression of hydronephrosis. He had developed iatrogenic urinary incontinence after the procedu", "role": "user" }, { "content": " res and had an indwelling Foley catheter <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 45-year-old lady presented with complaints of diminished vision for distance and near in the right eye for the past 3 months. She had no other ocular complaints. On examination, the best-corrected visual acuity was counting fingers at 2 m in the right eye and 20/20 N6 in the left eye. Anterior segment evaluation, intraocular pressures, and ocular motility were normal in bo", "role": "user" }, { "content": " th eyes. No proptosis was noted. Right eye fundus showed a serous retinal detachment with underlying diffuse, subretinal yellowish-cream colored infiltrates whereas the left eye was normal []. The infiltrates were largely situated on and around the posterior pole with the periphery being uninvolved. The vitreous cavity was clear with no signs of inflammation. Fundus fluorescein angiography showed hypofluorescence during the arterial phase and progressive hyperfluorescence during the subsequent phase. Pin-point discrete leakages were seen from the multiple lesions in the late phase along with disc leakage []\nA clinical diagnosis of choroidal metastasis was made, and a detailed systemic history was elicited in order to localize a primary tumor. Her systemic history was significant: She gave a history of frequent headaches and a six month history of menorrhagia. A metastatic screening in the form of ultrasound of the abdomen, liver function tests, serum lactate dehydrogenase, and a gynecological consult were requested. Gynecological examination revealed an ulcerative mass arising from the cervix measuring approximately 4 cm × 4 cm × 3.5 cm, which bled on touch. A biopsy of the mass was performed which confirmed the diagnosis of poorly differentiated adenocarcinoma of the cervix with perivascular and perineural invasion. High resolution computed tomography (CT) scans of the chest showed multiple pleuroparenchymal metastatic nodules [Fig. and ]. Positron emission tomography CT–(PET-CT) scan was performed which showed a bulky uterine cervix with increased metabolic activity. Multiple, hypermetabolic enhancing right supraclavicular, retropectoral, and mediastinal lymph nodes were noted. Multiple, hypermetabolic pleuro <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "We report the case of an 82-year-old Afro-Brazilian man (weight 72 kg) who presented to the intensive care unit (ICU) in the immediate postoperative period of elective surgery with signs of hemorrhagic shock. This surgery was performed to treat iliac artery aneurysm with endoleak type 1 to 1B with placement of Endurant™ IIS trimodular prosthesis. His previous medical history included dementia, arterial hypertension, tobacco smoking, ischemic heart disease, and aortic insufficiency. He denied consuming alcohol. At home, he was stable and felt well. He was calm and performed his daily activities under medical supervision, despite early stage dementia. He had no motor deficit, only idle speed typical of the elderly. His blood pressure was controlled, with no clinical signs of heart failure. According to his family, he had a good quality of life. Three months earlier he had undergone vascular surgery to treat an aneurysm in his common iliac artery with endoprosthesis. The surgery had no complications and he was rehabilitated at home. However, 3 days prior to hospital admission he had a computed tomography scan. The res", "role": "user" }, { "content": " ult of imaging showed an increase in aneurysm size in his common iliac artery. Then a new surgery was indicated for the treatment of the aneurysm.\nThe present surgery was performed under general anesthesia, with hemodynamic instability throughout the procedure, which required norepinephrine. Iliac dissection technique was difficult; there was loss of blood and a need for suture and compressive dressing. Cefuroxime was administered intravenously in the operating room at 1.5 g intravenously and maintained every 8 hours postoperatively. In addition, 3500 ml of crystalloid, and 1 unit of RBC were administered. Our patient left the surgery without a distal pulse; 31 mL of contrast was needed. He presented hypotension and alteration of consciousness after anesthesia wore off. His low blood pressure was increased with metaraminol use, a sympathomimetic drug that produces peripheral vasoconstriction (compresses peripheral vessels) by direct action on <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 65-year-old white woman was hospitalized for a right hypochondrium colicky pain radiating to the ipsilateral subscapularis region. Her pain was not related to food and posture. It appeared during the previous week and persisted despite nonsteroidal anti-inflammatory medication. A clinical examination showed that her abdomen was swollen in the right iliac fossa and the presence of voluminous palpable mass that was hard, fixed", "role": "user" }, { "content": " to <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The patient was an 86-year-old woman who suffered neoplasia on the right cheek and right frontotemporal area for 2 years. The patient had a history of lacunar infarction, cerebral insufficiency, hypertension, and diabetes. The facial neoplasm grew slowly for 2 years and accelerated in the last month before she was seen, with ulceration and crusting. The size of the neoplasia was 4.0 cm × 4.0 cm, 3.0 cm × 3.0 cm and 2.5 cm × 3.0 cm (Fig. ).\nEnhanced CT and MRI of the maxillofacial region were performed preoperatively. The surgery area was simulated using 3D image technology for the virtual surgery design and operation to be implemented. A safe resection range of 1.5 cm on the outer edge of the lesion was designed. One day before the surgery, the shape and range of the perforating branches were determined by Doppler ultrasound. The size and shape of the SCAIFP were designed to be elliptical and 15 cm × 7 cm in size.\nThe maxillofacial tumour extended resection and supraclavicular flap repair operation was performed. The neoplasia was completely resected, and the facial nerve was preserved. The defect was approximately 18.5 cm × 7.5 cm. Pathological analysis of the frozen tissue showed low-", "role": "user" }, { "content": " medium differentiated squamous cell carcinoma with negative margins. Based on the position of the transverse carotid <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "M.G. 30-year-old male patient was admitted to the Department of Ear Nose Throat in DEU Hospital with the main complaint of not hearing the safety belt alarm in his car. Subsequent to his history taking, he was referred to occupational disease outpatient clinic in the hospital. He has been working as a home agent for a call center for the last 50 months. He has been working 8 h a day and 6 days a week. His work equipment consists of a monitor and a headset.\nHis equipments have no amplificator. The system is accessed by a password and the incoming calls are directed by team leaders to the related operators. He was mainly serving clients from mechanical maintaining and repair sector clients, thus he described frequent high pitch noise and parasite particularly at the beginning of the conversations. He said, “I have to control the noise level manually since I do not have the amplificatory device….” In his occupation", "role": "user" }, { "content": " al history, he describes the time between high noise level and parasite and manual modification as 3-5 s. He also described ear pain after some of these exposures. A call is received every 3-5 min; 17% of the work time is passed in passive mode, waiting for a call. The breaks are managed by the operator himself or by the team leader. He also mentioned other employees with hearing problems during occupational history, but we did not have a chance to examine any other employees yet.\nHe reported no periodical health examinations and very limited occupational health and safety training was given to him only at the beginning of the job. Although we requested personal noise exposure and environmental noise measurements from the company, no answer was received. The audiometry test at the start of work was normal [].\nThere was no history of smoking or alcohol use, regular drug use, autotoxic drug use, chronic diseases, and exposure to high-pitched noise such as the explosion in his personal and family history <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 70-year-old man complaining of worsened dyspnea was evaluated in the emergency department. His past medical history included diabetes. In addition, several years prior to presentation, he had visited dermatology clinics for intermittent erythema and swelling in the right auricle and deformity of the nose, but no specific disease was diagnosed. The patient complained of intermittent breathing difficulties for the past year, which was getting worse. His vital signs upon arrival to the emergency department were as follows: body temperature 36.9°C, heart rate 125 beats/min, blood pressure 165/90 mmHg, and respiratory rate 35 breaths/min. Physical examination revealed loud inspiratory stridor on auscultation and inharmonic movement of the thorax and abdomen on respiration, similar to paradoxical respiration. There was no abnormality in the laboratory findings, and plain chest radiography was normal. Because of acute respiratory failure in which oxygen saturation was not maintained, the patient was intubated and moved to the Intensive Care Unit (ICU). Flexible bronchoscopy was immediately performed, and it showed dynamic luminal narrowing of the middle to distal trachea, especially on expiration. On ICU day 3, the patient was stabilized and extubated. A computed tomography (CT) scan with 3D reconstruction of the trachea and bronchus and repeated flexible bronchoscopy were obtained after extubation to confirm the upper trachea lesion. The CT scan showed luminal narrowing between inspiration and expiration at the level of the aortic arch without stricture (). The repeated flexible bronchoscopy revealed significant narrowing of the upper trachea that worsened during expiration without abnormality of vocal cord movement or larynx. In addition, we could not find the cartilage ring in the upper trachea (). A few hours following extubation, the patient experienced severe respiratory distress with stridor, and endotracheal intubation was performed again. On physical examination, the auricular cartilage was floppy and misshapen, and a saddle nose deformity was observed (). Based on the presence of bilateral auricula", "role": "user" }, { "content": " r chondritis, <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 52-year-old man with spontaneous pain and swelling in the right tongue region consulted his regular dentist, who referred the patient to our hospital in July 2015. A lesion with an induration of 7 × 10 mm was found on the right tongue (Fig. A). There was an irregular surface and ulceration in the lesion. He was diagnosed with squamous cell carcinoma of the right tongue via pathological examination in August 2015 (Fig. B). Contrast-enhanced computed tomography (CT) showed a contrast region with a width of 18 mm and a depth of 11 mm in the longitudinal direction of the tongue (Fig. C). Magnetic resonance imaging (MRI) and contrast-enhanced CT showed no evidence of cervical lymph node metastasis. From the examination results, he was diagnosed with tongue cancer of the right side (cT2N0M0, at stage II). The pat", "role": "user" }, { "content": " ient underwent a partial tongue resection and supraomohyoid neck dissection in September 2015. For the resection, <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 48- year-old Chinese woman, gravida 4, para 2, was admitted to our hospital due to abdominal pain for 1 month. The clinical features of the patient at baseline were summarized in Table . The patient had a history of tubal ligation and denied asbestos exposure.\nFifteen years ago, the patient was diagnosed with a uterine myoma, which was about 8 cm in diameter. Instead of undergoing surgery, she opted for regular check-ups. One month ago, she developed abdominal pain and ultraso", "role": "user" }, { "content": " nography showed a 12 × 11.4 × 9.8 cm heterogeneous <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 80-year-old male patien", "role": "user" }, { "content": " t who was found to have <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 55-year-old, Caucasian woman was referred to our tertiary women’s heart center for persistent chest pain, palpitations, and dyspnea. Her medical history included hypertension, dyslipidemia, chronic anxiety, and bilateral non-obstructive carotid atherosclerosis. She had no prior history of diabete", "role": "user" }, { "content": " s mellitus, <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 15-year-old female presented with complaints of pain in the right lowe", "role": "user" }, { "content": " r limb and back for 1 <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 69-year-old female was referred to our clinic for an incidental finding of a large Morgagni hernia found on a recent CT chest scan for lung cancer screening. Patient reported occasional shortness of breath after prolonged ambulation but denied chest pain. She did have remote history of acid reflux symptoms but nothing recently. She denied issues with prematurity or issues with development as an infant, chest trauma, or MVA history. She did complain of occasional right shoulder pain but attributed this to arthritis. Denied history of heart attack, stroke, DVT, or PE. She had a 30-pack-year smoking history but quit a year prior. She was up-to-date on her colonoscopy, current within the past year. She denied hematochezia and melena, bowel habit changes or major body weight changes as well as any current abdominal pain. On examination her vitals were within normal parameters. Heart and lungs were unremarkable. Abdominal examination was soft with normal bowel sounds and nontender. Remainder of examination was unremarkable. Laboratory values included a normal CBC and BMP. A CT chest scan had demonstrated a large retroxyphoid hernia of Morgagni involving several loops of small bowel and transverse colon located in the right inferior hemithorax (Figs and ). No evidence of acute incarceration or strangulation were noted. A detailed discussion was undertaken with the patient regarding her hernia and she was consented for a laparoscopic repair with mesh.\nPatient underwent a laparoscopic approach in lithotomy po", "role": "user" }, { "content": " sitioning with the primary surgeon working between the legs. Three working ports were used, a <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 5-year-old child resident of Delhi, India, was shifted to a quarantine facility with his mother in early April as he was diagnosed with highly contagious illness of COVID-19.\nHe had a history of contact with COVID-positive patients and had mild symptoms which included runny nose and dry cough. His mother and other family members tested negative. Since he was a young child and could not be quarantined alone, so his mother was quarantined with him as his caregiver. He was a perfectly healthy child, and this was the first time since birth he was admitted in a hospital facility.\nThe child, initially, felt intrigued, but this did not last long. He realized that his mother was not letting him share her bed and maintaining distance with him and he was not allowed to go out. There was no television or toys to play with, and his father and sister were not allowed to meet him. He became uncomfortable in confinement. He was made to understand that it was essential for him to get well, but it was becoming difficult for him to cope. He used to get scared by seeing the health-care staff doffed in personal protective equipment (PPE). He was very noncooperative during the nasopharyngeal and oropharyngeal sampling procedure and used to get aggressive and violent. The health-care staff also found it difficult to communicate with the child because of Grade 3 PPE despite their extraordinary e", "role": "user" }, { "content": " fforts to care for the child. The mother <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 52-year-old Japanese man with lower abdominal pain underwent lower endoscopy, revealing a type 2 lesion with the entire circumference raised in the rectosigmoid colon. He was diagnosed with rectosigmoid colon cancer and underwent endoscopic stent placement as a bridge to surgery for large bowel obstruction. He was found to have multiple lung metastases and a horseshoe kidney on CT scan (Fig. ). 3D-CT angiography showed an aberrant renal artery at the isthmus from 3 cm under the inferior mesenteric artery (IMA) branch of the aorta (Fig. ). Laparoscopic anterior rectal resection was performed with a five-port conventional technique in which sigmoid colon and upper rectum were mobilized via a medial approach. During the operation, the IMA, left ureter, left gonadal vessels, and hypogastric nerve plexus were identified and preserved (Fig. , ). The root of aberrant renal artery was not visualized. The root of the IMA was located considerably cephalad to the renal isthmus, and the left branch of aberrant renal artery that was close to IMA was detected and preserved (Fig. ). The specimen was removed through a small laparotomy wound, and intraperitoneal r", "role": "user" }, { "content": " econstruction was <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "We describe the case of a 34-year-old gravida II para l woman, with a gestational age of 26 + 3 weeks at admission, who had a relatively healthy 4-year-old child with her 40-year-old husband of non-consanguineous marriage. She had been on injectable contraception for 2 years and had regular menses for 6 months before the pregnancy. She had antenatal care at a local health center and was vaccinated with tetanus toxoid once and supplemented with iron for 3 months. She was screened for retroviral infection, hepatitis, and syphilis and it was documented nonreactive. She had no anatomic scan at early gestation. She came to Felege Hiwot Referral Hospital with the chief complaint of severe and persistent headache of a day’s duration which was occipital in location associated with blurred vision and generalized body swelling of 1 week’s duration. She had no other danger signs in pregnancy. Her past gynecologic history, medical history, and surgical history were uneventful. She is Amhara by ethnicity. She had no known family history of hereditary or chromosomal disorders.\nHer blood pressure at admission was 180/120 mmHg and pulse rate was 84 beats per minute; her respiratory rate was 22 breaths per", "role": "user" }, { "content": " minute and she was afebrile. She had pink conjunctiva and <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 84-year-old male resident of a nursing home facility of Hispanic descent was brought to our emergency department (ED) for respiratory distress and altered mental status. He was intubated promptly on arrival to the ED. His past medical history was significant for intracranial aneurysm with bleeding following VP shunt placement, ischemic stroke with aphasia and paraplegia, and percutaneous endoscopic gastrostomy (PEG) tube placement. His vital signs and clinical laboratory results are presented in Table .\nThe clinical picture was suggestive of septic shock. We ordered a sepsis workup including two sets of blood cultures and urine culture. The patient was treated with aggressive intravenous fluid hydration and broad-spectrum antibiotics (vancomycin and meropenem).\nA non-contrast computed tomography (CT) of the chest, abdomen, and pelvis revealed bibasilar pulmonary atelectasis without focal infiltrate and the presence of a right-sided VP shunt catheter traversing the right neck, the right chest, and the right abdominal wall; the tip of the catheter was located within the", "role": "user" }, { "content": " gastric lumen and had likely entered <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 68-year-old Hispanic man with ESRD initially presented to an outside urgent care clinic with a 3-day history of a painful rash over the right thorax. His examination revealed a dermatomal, vesicular eruption at the T9 dermatome consistent with zoster reactivation. He was started on oral acyclovir 800 mg five times daily.", "role": "user" }, { "content": " The recommended renal dosing for a patient receiving dialysis <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 3.5-year-old girl was referred to a tertiary care hospital in Riyadh, Saudi Arabia from one of the Ministry of Health Hospitals, for neuromuscular evaluation of congenital contractures on August 6, 2011. The patient's mother confirmed a full term of a normal pregnancy with normal fetal movements which is a sign that the fetus is growing in size and strength. Cesarean section was recommended for delivering the patient due to prolonged labor. Although there were no perinatal problems reported, the patient was born with contractures particularly affecting her fingers, knees, and feet. Over time, those contractures improved with periodic physiotherapy sessions particularly her thumbs and 4th and 5th fingers which were often flexed in the palm. According to her parents, the patient is cognitively intelligent, and both her speech and language are matching the 99th percentile. On the contrary to the negative progression of this condition, there was a significant improvement where she was able to crawl and stand on her knees at an early age. Moreover, she is not on any medications, has no known allergies, and has never been hospitalized nor had any surgery.\nThe patient is followed regularly by orthopedics for consideration of soft tissue release particularly with current talipes more obvious on the left side. She also has pterygium webbing of the knee joints limiting them from the extension. Whereas ES has an unknown incidence, it is more common among children from consanguineous relationships. Therefore, the family pedigree was checked, and it was found that the parents are double first-degree cousins, and they have 2 girls and 1 boy who are healthy with no similar family history reported.\nUpon arrival to the hospital and after documenting the patient's medical history, physical examination showed the following: temperature 37.1°C, respiratory rat", "role": "user" }, { "content": " e 20 breaths/min, pulse rate 96 beats/min, blood pressure 110/60 mmHg, and blood oxygen saturation 96%. Furthermore, weight was <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "In a 44-year-old female Caucasian patient, adenocarcinoma of the oesophagus located in the gastro-oesophageal junction (33 to 39 cm) was diagnosed in August 2007. The disease was Stage III (T3 N1) because of adventitial involvement and proof of suspectly enhanced mediastinal and paraoesophageal lymph nodes. The patient underwent preoperative (neoadjuvant) chemotherapy using ECF (intravenous epirubicin 50 mg/m2 and cisplatin 60 mg/m2 every 3 weeks at day one respectively, with continuous infusion of 5-FU 200 mg/m2 per day). Three cycles of the intravenous chemotherapy were administered after implantation of a central venous access (,). The tip of the catheter was advanced to the distal part of the superior vena cava (SVC) from the left subclavian vein that was approached by percutaneous implantation using Seldinger technique in local anaesthesia. Following subcutaneous tunnelling the infusion port was embedded in front of the left pectoral muscle fascia.\nThree month following the beginning of the neoadjuvant chemotherapy the patient proceeded to surgery. A proximal gastric resection and transhiatal subtotal oesophagectomy without thoracotomy through median laparotomy and left sided cervical incision was performed. Proximal gastric resection, oesophageal resection and reconstruction were performed in a single operation. The oesophageal substitute was positioned in the posterior mediastinum in the original oesophageal bed (gastric pull-up). Following the gastric pull-up a feeding nasogastric tube was positioned in the substitute and bilateral chest drains were performed. The patient was monitored up to the third postoperative day on the intensive care unit. All drains were gradually removed until the seventh postoperative day. The postoperative course was uneventful, except for a cervical wound healing complication due to a slight leakage of the gastro-oesophageal anastomosis. Temporarily feeding was conducted by nasogastric tube, and the leakage was successivel", "role": "user" }, { "content": " y occluded by fibrin sealant via endoscopy. The patient was hospitalised up to the 28th postoperative day. One month following the operation endoscopy confirmed a healed cervical anastomosis. Therefore <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 25 ", "role": "user" }, { "content": " year old G3P2L2 at 15 weeks of pregnancy was referred to the emergency of our hospital from another Centre with diagnosis of pregnancy with acute abdomen. She had previous two uneventful vaginal deliveries at home with last child birth 3 years back. She presented to our emergency with pain abdomen for 2 days and vomiting for 1 day. There was no complaint of per vaginal bleeding. She gave no history of medical abortion or any instrumentation done. She had gone to a rural hospital for this complaint where she was conservatively managed and an obstetric ultrasound was done documenting a 15 weeks single live intrauterine pregnancy. But when her condition started deteriorating, she was referred to our centre for further management. Our hospital, B.P. Koirala Institute of Health Sciences is a tertiary care referral hospital in Eastern Nepal.\nOn examination in our Obstetric emergency, she was ill looking with severe pallor. Her pulse was 140 beats/min, blood pressure 90/50 mmhg, respiratory rate 28 cycles/min. On abdominal examination, there was generalized tenderness. Bowel sound was present. On per speculum examination of vagina, there was no cervical pathology and no active bleeding was noted. On per vaginal examination, the uterine size could not be assessed due to tenderness and voluntary guarding. There was fullness in anterior fornix and tenderness in bilateral fornices.\nAfter admission, investigations were sent, blood arranged and resuscitation started immediately. Investigations sent in our hospital were: B positive blood group, Hb: 2.8 gm/dl, RBS: 78mg/dL, HIV, HepBsAg and VDRL negative. Ultrasonography done in emergency showed intrauterine pregnancy of 15 weeks period of gestation with no cardiac activity and hemoperitoneum. The patient was immediately prepared for emergency laparotomy. Abdomen was opened by midline infraumbilical incision. There was hemoperitoneum of approximately 1500ml. On further exploration, there was a fetus lying within the intact amniotic sac () in the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 4-year-old male child who had already undergone primary repair of EB at another hospital, at the age of one year, presented to our paediatric surgery outpatient department. He had history of passing purulent urine from the defect in lower abdomen, hematuria and fever with chills intermittently for last ten months. The defect progressively increased in size during this period. A dirty yellowish stone was visible through the defect for two months. Epispadias was not repaired []. The child was not gaining weight. The socioeconomic condition of the child's family was poor and they were illiterate, thereby resulting in poor follow up after initial surgery. On examination, features of sepsis were present in the form of fever, tachycardia and low blood pressure. The upper abdomen was soft. There was a large defect in lower abdomen where a large stone was impacted. Purulent urine could be seen coming from the side of the stone.\nThe patient was resuscitated and investigated. The haemoglobin was 5.6 gm/dl, total leucocyte count was 20,750/cumm, blood urea 126 mg/dl and serum creatinine was 2.7 mg/dl. Serum calcium, phosphate, uric acid levels were normal. The ultrasound abdomen showed bilat", "role": "user" }, { "content": " eral hydroureteronephrosis. Urine <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "We informed the patient that data from his case would be submitted for publication, and he provided consent.\nA 30-year-old man with no underlying disease sustained a crush injury to his foot and ankle and lower legs in a car crash. He was brought to our hospital in an ambulance. He sustained open fractures to the left foot and ankle (Gustilo Anderson classification Type IIIB) and bilateral open tibial shaft fractures(the right was aTypeI and the other was a TypeII). The tarsal bones were crushed, and a part of the bone protruded from the wound (). There was no damage to important internal organs, such as the brain or heart, and his physical status was stable. The radiograph and computed tomography scan showed dislocation of the ankle joint; severe foot and ankle instability were seen ( and b). The mangled extremity severity score (MESS) was six and the limb salvage index (LSI) was five on arrival. Amputation is recommended when the MESS is ≥7 and LSI is ≥6 [,]. We opted to perform limb salvage, because the blood flow was maintained by the posterior tibial artery and the sensory nerve in the foot sole was intact. Table 1 summarizes the lesion characteristics.\nThe ankle and foot were stabilized using Kirschner wires (K-wire) on the day of injury. We maximally removed the necrotic tissue a", "role": "user" }, { "content": " nd bone. We also provided temporary fixation for both open tibial shaft fractures with external <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 83-year-old woman, with a height of 1 meter and 65 cm and a weight of 85 kg (BMI = 31.22), was transferred to our department because of a reverse pertr", "role": "user" }, { "content": " ochanteric-subtrochanteric fracture AO 31-A3 (). The patient had a cardiovascular disease of moderate severity, though her social life was very active, and the Harris Hip Score (HHS) [] and the Short Form 12 Health Survey (SF-12) [] were both 94 points (). The anesthetic risk was ASA 3 [], and she did not require intensive care after surgery. After reduction, internal fixation was done using a short Affixus® nail (Zimmer Biomet™, Warsaw, Indiana, USA) which is 180 mm long. The shaft was 9 mm wide, the lag screws were 100 mm long, and one distal static locking screw was used (). In the 1st postoperative day, rehabilitation began, and by the 2nd day, she was walking with total progressive weight-bearing. She was discharged on the 7th postoperative day. Six months after surgery, at the last control, the HHS was 66 and the SF-12 was 74, and the radiographs showed subtrochanteric nonunion and medial displacement of the distal fragment (). Thereafter, the patient seek medical assistance in another hospital. Six months later, she underwent radiographic studies which showed incomplete breakage of the nail at the hole for the locking screw (), though no surgical treatment was indicated. There was no pain in the hip, and 2 years following primary surgery, radiographs done in the other hospital showed further incomplete nail breakage at the hole for the lag screw (). No further treatment was planned, and later on, the patient reported mild pain while flexing the hip. One year later, i.e., three years after surgery, the patient seek further assistance because of the sudden severe hip pain, and the radiographs showed complete fracture of the nail at both the proximal <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 26-year-old female was admitted to the Department of General Surgery of Daping Hospital and Research Institute of Surgery (Chongqing, China), due to the presence of a painless mass in the left breast for three months. The patient indicated that the mass had recently grown rapidly. The patient had no notable medical history or family history of carcinoma. Clinical examination revealed a 3×2-cm firm irregular mass in the upper inner quadrant of the left breast. There was no change in the appearance of the local skin, no di", "role": "user" }, { "content": " scharge from, or retraction of, the nipple. A <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 84-year-old male resident of a nursing home facility of Hispanic descent was brought to our emergency department (ED) for respiratory distress and altered mental status. He was intubated promptly on arrival to the ED. His past medical history was significant for intracranial aneurysm with bleeding following VP shunt placement, ischemic stroke with aphasia and paraplegia, and percutaneous endoscopic gastrostomy (PEG) tube placement. His vital signs and clinical laboratory results are presented in Table .\nThe clinical picture was suggestive of septic shock. We ordered a sepsis workup including two sets of blood cultures and urine culture. The patient was treated with aggressive intravenous fluid hydration and broad-spectrum antibiotics (vancomycin and meropenem).\nA non-contrast computed tomography (CT) of the chest, abdomen, and pelvis revealed bibasilar pulmonary atelectasis without focal infiltrate and the presence of a right-side", "role": "user" }, { "content": " d VP shunt catheter traversing the right neck, the right chest, and the right abdominal wall; the tip of the catheter was located within the gastric lumen and had likely entered through the PEG tube insertion site (Figures -). The PEG tube was outside the gastric lumen, terminating in the abdominal wall that was evidenced in the repeat CT scan confirmed that patient had abdominal wall cellulitis and localized abscesses around the PEG tube insertion site (Figure ). Medical records from another facility confirmed previously normal positioning of the PEG tube and normal intraperitoneal positioning of VP shunt catheter one year prior.\nGiven the malposition of the VP shunt inside the gastric lumen, we suspected VP shunt infection or meningitis/encephalitis and subsequently lumbar puncture was performed; the results of the cerebrospinal fluid (CSF) analysis were unremarkable. Blood cultures and urine culture results were negative.\nThe wound culture was positive for Proteus mirabilis sensitive to carbapenems and piperacillin/tazobactam. We debrided the abdominal wall and drained the abscess. Intravenous antibiotic coverage was continued according to the sensitivity testing, and patient received <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 82-year-old man without any symptoms was referred to Hino Municipal Hospital, because of a faint infiltrative shadow observed in the left lower lung field on routine chest radiography (). The patient did not complain of chest wall swelling; however, the physical examination revealed a subcutaneous soft tumor on the left anterolateral chest wall without tenderness or a skin surface abnormality. The transcutaneous oxygen saturation of peripheral artery was 94% under the room air inhalation at the diagnosis. He had never smoked previously and was taking medication for hypertension and asymptomatic cerebral infarction. Contrast medium-enhanced chest computed tomography (CT) revealed an enhancing tumor (58 × 33 mm in size) on the left anterolateral chest wall with destructive changes in the 6th rib bone (), corresponding to the abnormal shadow on the chest radiograph. In addition, a massive filling defect of the right proximal pulmonary artery was detected with pulmonary nodules in the right lung (Figures and ). Importantly, the “mass” in the pulmonary artery was, unlike in CPTE, weakly enhanced with contrast medium. Pulmonary nodules existed only on the ipsilateral side of the pulmonary artery mass and formed a mold-like shape in the peripheral pulmonary arteries. Further examination did not identify another site of suggestive malignancy, except for prostate cancer using body CT and head magnetic response imaging (MRI). A laboratory test did ", "role": "user" }, { "content": " not show any significant abnormalities, including those of D-dimer and tumor markers. These findings implied a possible diagnosis of primary <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 58-year-old African-American female presented to a hospital emergency room with a superotemporal marginal corneal ulcer of the left eye two clock hours in length, with mild corneal thinning. Uncorrected visual acuity on the initial exam was 20/30 in the right eye and 20/50 in the left. Both eyes showed diffuse punctate corneal epitheliopathy in the palpebral fissure. Her past medical history included alcohol use since the age of 14, serious alcoholism since the age of 34, and chronic pancreatitis and diarrhea since the age of 52. She reported that she drank 6–12 beers per day. She had a smoking history of >50 pack-years as well as a history of gastrointestinal bleed, liver cirrhosis, cholecystectomy, chronic obstructive pulmonary disease, and anaphylactic reaction to peanuts. She had lived in urban USA since birth.\nAfter corneal culture, the patient was started on hourly topical moxifloxacin 0.5% eyedrops in the left eye as well as artificial tears in both eyes. Cult", "role": "user" }, { "content": " ure was positive for alpha-hemolytic streptococcus and catalase-positive Gram-positive cocci in groups with preliminary <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "Our patient was a 39-year-old female with a history of hypertension and preeclampsia who presented to an outpatient visit with sudden on", "role": "user" }, { "content": " set, severe, substernal chest pain. Other associated symptoms at the time of presentation were diaphoresis, dizziness, and nausea. An <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The first case is that of a 3-year-old male with developmental delay and multiple musculoskeletal abnormalities including bilateral cleft feet who underwent right tibial supramalleolar derotational osteotomy for symptomatic external tibial torsion. The osteotomy was performed with an oscillating saw under irrigation and completed with an osteotome. A fibular osteotomy was performed at a different level. The tibia was derotated approximately 30 degrees, and fixation was obtained with three percutaneously placed 0.062 Kirschner wires.\nPostoperatively, the patient was maintained in a cast with wires in place for 9 weeks, at which point, radiographs demonstrated complete consolidation of the fibular osteotomy with evidence of scant bridging callus at the tibial osteotomy site (). The bridging callus was thought to be an indication of healing; therefore, pins were removed and the patient was advanced to weight-bearing as tolerated. Unfortuna", "role": "user" }, { "content": " tely, subsequent follow-up failed to show progressive healing of the tibial osteotomy with concern for a delayed union. Laboratory workup was negative for infection or metabolic abnormality. The child was managed conservatively for a total of 6 months, and at the time of the 6-month follow-up, nonunion was diagnosed, as there had been no radiographic progression of healing during this period ().\nThe patient was taken back for revision open reduction with internal fixation, utilizing a 6-hole 2.7 mm plate in compression mode with supplemental demineralized bone matrix (). In order to achieve compression at the nonunion site, a concomitant fibular osteotomy was again created proximal to the tibial nonunion. Intraoperatively, the nonunion was found to be hypertrophic and had obliterated the medullary canal, which required drilling in order to reestablish one. Following revision surgery, the patient was immobilized in a cast for one month after which he was progressed to weight-bearing and went on to an uneventful union by the 3-month postoperative time point (). The patient later was taken back for hardware removal, Achilles tendon lengthening, and cleft foot reconstruction 28 months later <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 43-year-old male patient attended a dental clinic with the prosthetic crown of tooth 24 in hand, with the remaining fractured root core, part of which was inside the root canal (Figures and ).\nClinical and radiographic examination revealed the absence of a root fracture, which might preclude maintenance of the tooth (). It was also observed that the root canal had not been submitted to removal of sealing material up to the adequate length of 2/3 of the dental remnant to the root apex [, ]; the cast metallic core was short, which impaired the intraradicular retention.\nDuring clinical examination, it was observed that the dental remnant presented satisfactory conditions for a new rehabilitation with placement of an intraradicular core and a total prosthetic crown. It was proposed to remove the portion of the cast core that was inside the root canal for later accomplishment of a new intraradicular cast core, using the existing metal-ceramic crown as a reverse template for the coronal portion of this future core.\nThis alternative was possible because there was no need for additional preparation (wear) of the dental remnant at the cervical level, which would impair the adaptation and reuse of the original prosthetic crown. Initially, root canal preparation (buccal and palatal) was performed by instrumentation with Gates Glidden drills at the appropriate length (2/3 of the dental remnant in the largest (palatal root canal), 1/2 of the dental remnant in the other canal (buccal)) ", "role": "user" }, { "content": " [, ]. Then, <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 64-year-old man visited the emergency room for abrupt-onset chest pain. He had underg", "role": "user" }, { "content": " one a <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 77-year-old man was presented with cardiovascular pathologies that included severe mitral regurgitation (MR) and moderate tricuspid regurgitation (TR). He had no history of congenital venous disease. He had recent shortness of breath with exertion. His New York Heart Association status was class II. Echocardiogram results showed severe MR due to P3 prolapse, moderate TR, and pulmonary hypertension. The left ventricular function was normal with ejection fraction at 61 % and coronary angiogram findings revealed no significant coronary artery stenosis. Renal function was normal with creatinine at 0.69 mg/dl and preoperative hematocrit at 41 %. A preoperative nutritional assessment showed a normal serum albumin level.\nThe patient underwent a mitral valve repair with P3 resection and suture, followed by ring anuloplasty and tricuspid anuloplasty procedures using a prosthetic ring via a right mini-thoracotomy. Cardiopulmonary bypass was established with antegrade arterial flow through the right subclavian artery, and bicaval venous drainage through the superior vena cava and right femoral vein. We checked the position of venous cannula by transesophageal echocardiography (TEE). Also, we confirmed the position under direct vision when performing tricuspid annuloplasty. Cardiac arrest time was 219 min and cardiopulmonary bypass time until declamping aorta was 262 min. During main procedure, cardiopulmonary bypass flow, mean arterial pressure, and central venous pressure (less than 5 mmHg) were stable within normal range. The value of hematocrit during cardiopulmonary bypass was between 22 and 25 %, and base excess was around −5.0 mEq/L. Blood transfusion was also performed. We observed no sign of poor venous drainage from his lower body, such as severe edema of lower extremity and ascites. While weaning from the bypass, the patient became hemodynamically unstable and the weaning became difficult. Soon thereafter, hemodynamic status worsened even while u", "role": "user" }, { "content": " nder the cardiopulmonary bypass due <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 30-year-old South Indian man presented with complaints of left sided headache and left sided facial pain, which was intermittent, sharp stabbing quality for past 3 months, severe for past 10 days. He had no history of fever, convulsions, loss of consciousness or ear, nose, throat bleed. Patient gave past history of head injury 10 years ago to the left skull for which he took no treatment and no imaging studies were done. Not a known diabetic or hypertensive. Patient denies history of smoking or alcohol intake. He is married with one child. Patient was moderately built and nourished with a body mass index (BMI) of 21 kg/m2. On physical examination, he was conscious, oriented, afebrile, general condition was fair and vitals stable. Right side of the face appeared normal. Left side of the face showed signs of hemi atrophy with minimal drooping of left eyelid (). Examination of the face revealed no sensory or motor deficits on both sides. Further, there was no other evidence of Horner’s syndrome, facial palsy, or hemi facial spasm. 5 years ago the same patient appeared normal with no obvious facial abnormality (). Systemic examination of the central nervous system (CNS) was normal. Fundus examination was normal. All other systems were found to be normal. Local examination, measurement were taken from the nasion to the tragus, nasion to angle of mandible, and mid chin to tragus of both right and left side (). The measurements showed hemi facial atrophy of the left side. Routine blood and urine investigations showed within normal limits (Table 2). Diagnostic radiological imaging were done in which ultrasound abdomen (USG abdomen) showed no organomegaly or free fluid. X-ray chest revealed no abnormalities and X-ray skull showed both sides equal (). Computerized tomogram brain (CT) showed Left minimal sub dural hygroma with no midline shift, and no evidence of cerebr", "role": "user" }, { "content": " al edema or cerebral atrophy ( <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "On the morning of admission, our patient, a 19-year-old African-American man with sickle cell anemia, felt himself to be in his usual state of health, although he had just been discharged the previous day from a hospitalization for acute chest syndrome. He ate breakfast and spent the day watching television. However, at approximately 5:45 p.m. when he used the bathroom, he noticed that he could not pull up his trousers due to weakness in his left arm. As he walked out of the bathroom, he noted that he was having difficulty walking because of weakness in his right leg. As his mother was helping him to his bed, his left leg also became weak. He began experiencing ‘shocking’ pains on both sides of his neck, which were unlike his usual pain, and also noted that he had an erection. These events transpired rapidly, within about six minutes, at which point his family called Emergency Medical Services (EMS) and our patient was transported to our hospital.\nOn arrival at our hospital, he was alert and oriented and cranial nerves II to XII were intact. He had flaccid paralysis of the bilateral upper extremities and the left lower extremity, and normal tone with 5 out of 5 strength in the right lower extremity. He had areflexia in the biceps, triceps, and brachioradialis bi", "role": "user" }, { "content": " laterally, hyper-reflexia at the left patella, and sustained clonus at the left Achilles. Sensation was intact throughout. The results of the rest of his physical examination were normal.\nRelevant medical history included asthma, recurrent acute chest syndrome (>10 episodes), and intermittent attempts at hydroxyurea treatment with poor compliance over the previous 10 years. Following the identification of silent cerebral infarcts, he was treated for the three years between 2005 and 2008 with exchange transfusions to maintain hemoglobin S < 30 percent; during this time he did very well. At 10 days prior to presentation <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 61-year-old Caucasian male was brought to the ER with an initial diagnosis of acute ST-elevation myocardial infraction by the emergency medical services (EMS). On further questioning, the patient denied history of chest pain, but complained of sudden onset generalized weakness and numbness. The patient had developed weakness of his legs and difficulty in passing urine one hour before arriving in the ER. Patient denied recent infections, headaches, nausea, vomiting, trauma or a similar neurological episode before. The patient had end stage renal failure due to poorly controlled diabetes and hypertensive heart disease for many years. He had been on routine hemodialysis thrice a week with each dialyzing session lasting for four hours for the past three years. The last dialysis was done the day prior to presentation. His medications included metoprolol 100 mg twice a day, simvastatin 40 mg daily, aspirin 81 mg daily and 70/30 insulin 30 units subcutaneously twice a day.\nOn examination, the patient's had a temperature of 98.2°F, respiratory rate of 20 per minute, heart rate of 90 beats per minute and a blood pressure of 150/90 mmHg. Examination of the cardiovascular system showed normal heart sounds with no murmurs. The respiratory system and gastrointestinal systems were normal. Central nervous system examination revealed an alert, awake and oriented patient with normal cranial nerve function. He had symmetrical and equal weakness of the lower limbs more than in the upper limbs. The muscle tone and the reflexes were also weaker in the lower limbs compared to the upper limbs. There was no sensory deficit. In the ER, blood tests including chemistry and complete blood count were sent. A bed side EKG and a chest X-ray were performed.\nBased on the initial two EKG strips done by the EMS and the subsequent two EKGs done in the ER (Figure: , ,", "role": "user" }, { "content": " , ) and the clinical back ground of end stage renal failure the diagnosis of hyperkalaemic flaccid paralysis was made <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The patient was a 9-yr-old Iranian girl presenting to the Pediatric Emergency Room of Moosavi Hospital, Zanjan, Iran in January 2017, with sudden onset of headache and recurrent vomiting, ataxia and history of 3 consecutive days of fever and malaise. There were left eye ptosis and decrement of left nasolabial fold in patient’s face. The patient had tremor and truncal ataxia. The force of the extremities and deep tendon reflexes were normal in physical examination. Her heart rate was 110 min, blood pressure 90/60 mm Hg and temperature 38.2 °C. The patient’s weight was 21 kg and had 133 cm height and head circumference was 52 cm. The patient had no history of head trauma.\nAn informed consent was obtained from her parents in order to publish data as a case report without publishing her name. Ethics Committee of the university approved the study.\nDiagnostic focus and assessment:\nThe patient underwent a brain CT scan without contrast in first day of admission preceded by CBC, diff, BUN, Cr, Na, K, Arterial blood gas sampling (ABG) and Urine analysis. On the second day, brain magnetic resonance venography (MRV) and magnetic resonance imaging (MRI) with flair, T1, T2 and DWI sequences and also EEG were ordered, then lumbar puncture with 3 samples was carried out. About 48 h after the MRI the patient became aggressive and had severe headache, nausea and vomiting plus ataxia and delirium, then the patient transferred to PICU and we decided to order the second CT scan and after the results, we asked for urgent neurosurgery consultation and the patient was prepared for brain surgery. The day after surgery the patient underwent brain CT scan without contrast again and laboratory tests were repeated. The patient underwent the last brain CT scan without contrast on thirteenth day and also had an EEG o", "role": "user" }, { "content": " n the same day. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 36-year-old male patient, presented to the emergency department on the 10th of January 2014, with intermittent ", "role": "user" }, { "content": " right sided abdominal pain for the past few months that was becoming severe in the preceding few days. The nature of pain was nonspecific and the location was diffuse. There were no associated lower urinary tract symptoms or fever. He has no comorbidities or history of urolithiasis. He was a smoker for the last 20 years. Physical examination revealed right-sided renal angle fullness. Rest of abdominal examination was unremarkable.\nUrinalysis showed microscopic hematuria with some proteinuria. Full blood count was within normal limits, whereas renal function test showed an elevated creatinine of 150 µmol/L. A plain abdominal film showed; a large, well-defined soft tissue swelling in the right hypochondrium and lumbar region. The patient was initially seen by the nephrology services, who arranged renal tract ultrasound (US), which showed a large clear cystic lesion measuring 20 cm × 16 cm in the right subhepatic region occupying the entire right lumbar quadrant. No contents seen with no septation. The right kidney was compressed by the cyst and could not be separately imaged from this lesion. The contralateral kidney was unremarkable. He was referred to urology clinic, where he was found to have a palpable mass that was dull to percussion occupying the right renal angle. After taking necessary measures against contrast nephropathy, the patient had a CT scan with intravenous and oral contrast of the abdomen and pelvis that showed a large thick-walled nonseptated noncalcific right renal cortical cyst (23 cm × 16 cm × 15 cm) showing enhancement of its thick walls, no right perinephric/pericystic fat stranding, preserved tissue planes with surrounding related organs.\nFor further assessment of drainage and function, the patient had an MAG3 renogram that showed a small right kidney with poor perfusion and excretion of the tracer. It contributed around 9% to the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The patient is a 31-year-old male with a history of hypertension, hypothyroidism, and hyperlipidemia who initially presented to his primary care provider with fatigue and lethargy. He had no past surgical history and his family medical history was noncontributory. He was found to have severe hypothyroidism with a thyroid stimulating hormone level of greater than 100. He presented to the Emergency Department (ED) at an outside hospital for concerns of ongoing leg swelling, fatigue, and lethargy in conjunction with hypothyroidism. Upon admission to the ED, he was found to have a deep vein thrombosis (DVT) in the popliteal vein. He was then started on enoxaparin sodium 100 milligrams twice a day and was scheduled for a thyroid ultrasound. The thyroid ultrasound displayed multiple bilateral hypoechoic thyroid nodules with the largest 3.5 cm in diameter. He underwent FNAB of the dominant left and right nodules with 5 passes each, using a 22 gauge needle under ultrasound guidance.\nThe procedure was reported to have gone well; however, several hours later he developed anterior neck swelling and difficulty breathing. An ultrasound at that time confirmed an intrathyroidal hematoma with concern for arterial disruption. The patient was fiberoptically intubated at the outside hospital for airway protection and transferred to a tertiary care center. Upon admission, computed tomographic angiography of the neck displayed a large intrathyroidal hematoma with an arterial blush concerning for active hemorrhage (). Enoxaparin sodium was held", "role": "user" }, { "content": " at the time of his admission to the tertiary care center. Interventional radiology was consulted for possible embolization of the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 61-year-old woman with poorly controlled diabetes mellitus and malnutrition was admitted to the local hospital for necrotizing fasciitis of the right thigh. She developed septic shock with diabetic ketoacidosis. Three days later, she had hematemesis, and gastrointestinal endoscopy revealed circular black mucosal changes throughout the entire esophagus (Fig. ). She was diagnosed as having AEN. As her general condition improved with intensive care, debridement, and treatment with antibiotics and a proton pump inhibitor, the color of the mucosa partially improved (Fig. ). One month later, endoscopy showed an esophageal stricture of the upper thoracic esophagus (Fig. ), which progressed to an esophageal obstruction after 3 months (Fig. ). She underwent open gastrostomy due to her inability to eat. She was referred to our hospital for surgical treatment 1 year and 4 months after the occurrence of AEN because of her strong desire for oral intake.\nEndoscopy revealed an esophageal obstruction, and the biopsied specimen at the blind end of the esophagus revealed esophagitis without any malignancy (Fig. ). Upper gastrointestinal imaging (UGI) confirmed complete esophageal obstruction at the upper border of the clavicle (Fig. ). Computed tomography (CT) showed circumferential wall thickening from the upper to middle thoracic esophagus (Fig. ). When she was referred to our hospital, her medical condition was poor, and she could not walk due to generalized muscle weakness. After rehabilitation for 8 months, she underwent esophageal bypass.\nFirst, the cervical esophagus was cut at the level of the suprasternal notch. In the initial plan, pedunculated jejunum was to be used for the esophageal reconstruction because of the uselessness of the stomach due to the gastrostomy. However, the shortening of the small bowel mesentery would not allow for a reconstruction with pedunculated j", "role": "user" }, { "content": " ejunum. Fortunately, a gastric tube, excluding the insertion site of the gastrostomy, could be created, and the esophageal bypass was performed using a gastric conduit via the percutaneous route. The remnant stomach <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 28-year-old male patient presented to our surgical emergency with a history of pus discharge per urethra and recurrent episodes of urinary tract infection (UTI) for 1 year. The patient had a history of cystolithotomy done 1 year ago for which he was seeking treatment outside; the operation details were not available with the patient. There was no associated fever, hematurea, loss of appetite or constipation. The urine stream was normal. On examination, we found the patient was of average build and all the vitals were stable. Abdominal examination showed a horizontal scar in the lower abdomen at the previous cystolithotomy site and external genitalia were normal. Gross examination of urine showed turbid urine with pus flakes. The patient’s blood parameters were within normal limits. On initial presentation, urine culture was done", "role": "user" }, { "content": " , yielding Klebsiella spp. for which appropriate antibiotics were <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 29-year-old female was under follow up observation at a local clinic for a mass in her left breast palpated 6 months prior to admission. Mass size increased due to pregnancy and showed inflammatory findings. She was thus transferred to our hospital for surgical treatment. Gestational ", "role": "user" }, { "content": " age on admission was 8 weeks. In her presurgical breast ultrasonography, in the area 4 cm from the ten <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 6-month-old boy was referred to our tertiary pulmonary service because of unexplained persistent respiratory distress and failure to thrive since birth. He was delivered at 36 weeks of pregnancy, with a symmetrical intrauterine growth retardation (IUGR). Otherwise, the pregnancy was uneventful, and he was admitted to the neonatal intensive care unit for 5 days because of unexplained tachypnea and respiratory distress, which improved during the neonatal period but never completely resolved. He is the first baby born to a young couple who were not consanguineous but were from the same tribe.\nPresenting with shortness of breath, persistent cough and intermittent fever, our patient was treated in different district hospitals as a case of bronchiolitis, pneumonia, recurrent wheezing and possible asthma. He received multiple courses of antibiotics, nebulized bronchodilators and inhaled steroids with no response. Also, he was diagnosed with gastroesophageal reflux disease (GERD) based on a barium meal findings associated with shortness of breath and cough after feeding. However, he did not show an improvement following anti-reflux management and nasogastric feeding. Despite an optimum nutritional management with a high protein and calorie formula, he continued to have failure to thrive.\nUpon arrival to our center at the age of 6 months, he had persistent respiratory distress in form of tachypnea, intercostal and subcostal recession together with ", "role": "user" }, { "content": " an oxygen saturation of 78% in room air. His breath <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 55-year-old male presented with grouped", "role": "user" }, { "content": " , fluid-filled lesions over the right side of the neck, shoulder <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 44-year-old female patient underwent total mastectomy of the right breast after being diagnosed with invasive ductal carcinoma. The sentinel biopsy was positive. Thus, axillary dissection of the lymph nodes was performed. She thereafter received chemotherapy, as well as radiation and hormone therapy.\nThe patient presented at our department after radiotherapy, chemotherapy, and hormone therapy with the desire for breast reconstruction. She appeared to be very athletic, without much subcutaneous fat tissue. Therefore, adequate autologous breast reconstruction was not a viable option. Despite the previous radiation therapy, the patient showed sufficient skin quality, so we decided to implant an expander. This was performed 1 year after ablation. Three months later, we exchanged it with an anatomic textured 275-mL implant with a moderate profile (Mentor Siltex, Mentor Worldwide LLC, Irvine, CA, USA).\nSix months later, the patient presented again, showing signs of Baker grade IV capsular contracture in her left breast. There were no clinical signs of deflation of the implant. The patient did not recall any trauma to the chest or breast, either before the surgical procedures or after. On the patient’s request, ultrasound imaging was performed instead of MRI, and no implant rupture was visible.\nThe decision to perform a capsulectomy with implant exchange was made based on the clinical symptoms, with the patient’s consent. During the operation, the leakage of the implant became obvious (). Interestingly the area of the leakage was in direct contact with a protruding bony spur of the 6th rib. The implant was examined closely, and we noted that a small amount of silicone gel had leaked out through a small hole in the surface that had been in direct contact with the exostosis (). The diameter of the leakage was about 2 mm. After the bony spur was ablated using a bone rongeur", "role": "user" }, { "content": " , a capsulectomy was performed and a new implant was inserted. Over 5 years of follow- <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 13-year-old boy presented to the surgical OPD (outpatient department) with history of a scrotal swelling on right side since 3 years, pain in right hemiscrotum for 10 days, and fever for 3 days. The patient started with a gradually increasing swelling of the right hemiscrotum for 3 years. 10 days before his presentation, he developed pain over the swelling which was dull aching and continuous in nature associated with fever which was mild and continuous. There was no precedent history of any trauma or exercise. On examination the patient had swelling of the right hemiscrotum with edema and erythema of the scrotal skin. Blue dot sign was absent. On palpation local temperature was raised, skin was tender, and testis was not palpable separately. Left side scrotum and testis were normal. On investigation hemoglobin was 12.8 g/dL, total leukocyte count was 12140 per microliter", "role": "user" }, { "content": " , and other blood parameters were within normal limits. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The patient gave written informed consent for publication of this case report and any accompanying images, and the presentation was approved by the institutional review board of Juntendo University (JHS 18-027).\nA 67-year-old male, 170 cm tall, weighing 72 kg, was scheduled to undergo left lower lung lobectomy via open thoracotomy for non-small cell lung carcinoma. He had no relevant medical history, and his preoperative blood examination revealed no abnormal findings. We decided to preoperatively insert a thoracic epidural catheter for postoperative analgesia.\nOn the day of surgery, no premedication was administered. He was monitored by ECG, noninvasive blood pressure monitoring and pulse oximetry. Before general anesthesia induction, the patient was positioned in the right lateral position for catheter insertion. We initially attempted the epidural puncture at the thoracic (Th) 6–7 interspace, which we changed to the Th 5–6 interspace aft", "role": "user" }, { "content": " er 15 min due to difficulty in an epidural puncture at the original site. Using a right paramedian <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "Eight years ago, a 31-year-old male patient presented with symptoms of dull back pain, insidious in onset, felt in the lower lumbar and gluteal region, accompanied by morning stiffness which initially improved with activity. Within a few months, the problems became persistent and bilateral. With the passage of time, he experienced neck pain and stiffness with restricted mobility. He was diagnosed with having AS based on available criteria. Then, after 8 years, at the age of 39 years, he experienced weakness of all four limbs which started gradually and was progressive for the past 1 year. It started with the right upper limb followed by involvement of the right lower limb. Both left upper and lower limb were also involved sequentially within a few months ", "role": "user" }, { "content": " with progressive wasting and atrophy of muscles incapacitating him to perform his daily works. There was also a history of slurring of speech and occasional choking along with flickering movement of the muscle. Bladder and bowel functions were normal. The patient is nondiabetic but hypertensive. There was no history of chronic obstructive airway disease, tuberculosis, or trauma. There was no history of fever, abdominal pain, convulsion, skin changes, diminished vision, ptosis, redness of the eye, or any episode of bloody diarrhea. He denied any substance or illicit drugs abuse. Family history was insignificant.\nOn clinical examination, general survey was unremarkable. Higher function and cranial nerve examinations were normal. The neck was stiff with restricted movements in all directions. Other signs of meningeal irritations were absent. The cranium was normal, but the spine was curved with concavity anteriorly. In motor system, there was gross atrophy of muscles of the shoulder and pelvic girdles and distal limb muscles without any sensory loss. There was gross atrophy of the tongue, and fasciculation was also seen. The tone was increased. Power was 3/5 in proximal group of muscles in all four limbs with severe weakness in distal muscles with bilateral claw <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 18-year-old healthy woman (gravida 2, para 1) had a spontaneous pregnancy of monochorionic diamniotic twins with unremarkable medical and family history. At the routine pregnancy check-up at 21 weeks’ gestation, an abnormal fetal heart chamber was identified in one of the twins, and the patient was referred to our center with a diagnosis of bilateral hydrothorax in one fetus. Prenatal ultrasonography showed that the massive area of fluid was of pericardial, not pleural, origin. An abnormal heart chamber (4 × 5 mm) was detected in the apex of the right ventricle in the four-chamber view (). The presumptive diagnosis was a ventricular diverticulum or ventricular aneurysm. The connection to the ventricle was narrow, color Doppler ultrasound detected blood flow in and out of the abnormal heart chamber, and M-mode assessment indicated normal synchronous contraction of its walls with those of the ventricle; these findings were consistent with a diagnosis of ventricular diverticulum. There was an anechoic space peripherally around the heart, and both lungs were severely compressed (>50% lung compression) into a posterior position in the fetal thorax. This finding distinguished our case from that of a pleural effusion manifesting as an anechoic space located peripherally around the compressed lungs. There was no evidence of other fetal structural abnormalities or hydrops, and no structural or functional heart defects were detected. The mitral valve apparatus appeared normal, and no arrhythmias or intracardiac thrombi were seen. We detected no sign of complications of monochorionic multiple birth, such as twin-to-twin transfusion syndrome or selective intrauterine growth restriction. Ultrasound scans of the other twin appeared normal.\nThe couple was counseled regarding the increased incidence of fetal chromosomal abnormalities, the possibility of pulmonary hypoplasia and progressive hydrops, and the potential effect on the other fetus caused by vascular communications i", "role": "user" }, { "content": " n the placenta. Pericardiocentesis and amniocentesis <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 33-year-old Filipino man was diagnosed at our center with Burkitt lymphoma in July 2011. Disease staging revealed an Ann Arbor stage IA disease. The patient had undergone kidney transplantation in 2007 for renal failure secondary to chronic glomerulonephritis and had been on immune suppressive treatment with sirolimus 2 mg daily since that time. The patient was treated with a methotrexate-free regimen consisting of six cycles of R-CHOP and achieved a complete remission (CR). Three months post-CR, the patient presented with pain in the right axilla, extending to the thumb, index, middle fingers and median", "role": "user" }, { "content": " half of the ring <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "In June 2016, an 80-ye", "role": "user" }, { "content": " ar-old Japanese man with no significant medical history was referred to Minamisoma Municipal General Hospital (Fig. ) for bloody stools and dizziness. He first noticed bloody stools in May 2015 and was aware of the possibility of colorectal cancer. However, he did not seek medical attention for over 1 year, reportedly because he considered the amount of blood trivial and did not experience other serious symptoms. It was only after considerable dizziness that he first sought medical consultation. His hemoglobin level was 7.4 g/dL with mean corpuscular volume of 78 fL at first presentation. Colonoscopy and abdominal computed tomography revealed a locally advanced rectal cancer.\nHe reported that he did not fear a cancer diagnosis. Regarding his life history, after he graduated from junior high school at age 15, he worked for the construction industry and retired at 73. Although he was married at 19 and had two children, he divorced at 42, and thereafter lived alone. He had never undertaken any type of cancer screening, although Minamisoma City provided multiple screening programs including biennial fecal occult blood tests for colorectal cancer []. He resided in the most central area of the city, with the nearest general hospital 1.0 km away.\nFurther detailed history taking revealed that he was exposed to social isolation after the 2011 disaster. Although he lived alone before the disaster, he hosted a neighborhood association with residents of the same generation and had many opportunities to socialize with friends. The association members were interested in health issues, and normally shared their health concerns with each other. In their gatherings, he had actually learned that colorectal cancer could cause bloody stools. However, the 2011 triple disaster, particularly the nuclear disaster, led to long-term evacuation of his neighbors. He lost contact with almost all his friends, and was unable to continue organizing the neighborhood association gatherings. He went outside less frequently and <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "We describe the case of a 7-year-old male who presented with a first episode of arterial ischemic stroke. The neurological evaluation revealed a left sided hemiparesis which was not involving the facial musculature. The initial CT scan revealed an area of hypointensity in the region of the right basal", "role": "user" }, { "content": " ganglia. More specifically, its anatomical contribution was extending to the anterior limb and the genu <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 11-year-old boy presented to the outpatient clinic with complaints of pain, deformity and shortening of the left arm (Fig. ). Physical examination revealed pathologic motion at the proximal part of the left arm and 8 cm shortening of the left upper extremity compared to the opposite side. According to his past medical history, he had admitted to another institution 4 years before due to pain, swelling and deformity on his left shoulder and upper arm. An expansile, lobulated lytic lesion in the proximal metaphysis of the humerus had been detected on radiographic evaluation (Fig. ). He had been initially treated by en bloc resection and reconstruction with cortical strut allograft in this center (Fig. a). The histopathol", "role": "user" }, { "content": " ogical results of the tissue samples had been found to be consistent with ABC. Serial follow-up radiographs showed failure of the fixation with nonunion of the proximal humerus (Fig. b). Second surgical intervention including excision of the graft material and implants had been applied in the same center, 1 year after the index operation. The defect area had been filled with calcium phosphate allografts, and patient’s arm had been immobilized in a sling. However, union of the humerus could not be achieved.\nRadiographs at the presentation to the author’s institution revealed evidence of proximal humerus nonunion with a large defect (Fig. a). His shoulder range of motion was completely restricted with unlimited elbow motion. His neurovascular examination was normal.\nSurgery was performed under general anesthesia. The patient was positioned at beach chair position, and deltopectoral exposure over the old scar tissues was used to reach the humerus. Curettage of the dead space, which included the previously inserted allografts, was performed carefully. However, it could not be possible to remove all allograft materials completely due to their adhesions to the surrounding tissues. Then, reconstruction of the defective area with fibular autograft was planned, and the length of the fibular graft was decided. After exposing the contralateral fibular bone <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 69-year-old male presented to the clinic with complaints of weakness in the left lower limb for the last four months followed by gradual numbness. In the past two months, the symptoms progressed to both lower and upper limbs and the patient had difficulty walking. On neurological e", "role": "user" }, { "content": " xamination, the patient had muscle weakness in both upper and lower limbs (motor strength 3/5), hyperreflexia (+3) in both patellar and Achilles reflexes, increased muscular tone in lower limbs, bilateral Babinski sign, alteration in tactile sensitivity, and perception of pain and temperature from the level of the nipple to the feet. Magnetic resonance imaging (MRI) showed a mass at the level of the vertebral body of C7 with the presence of an extramedullary tumor measuring 4.19 cm with infiltration of the corresponding articular facets and tumor exits through neural hole C7-T1 (Figure ). Axial images demonstrated the presence of an extramedullary tumor on the left side of the spinal canal causing spinal compression and displacement of the cord to the right (Figure ).\nThe patient underwent a C6-C7 laminectomy and tumor resection with near total excision. Three specimens in formalin were sent to the pathology laboratory which showed malignant mesenchymal neoplasia consisting of a vascular and solid pattern with an “epithelioid” aspect highly pleomorphic, hyperchromatic, frequent mitosis, and multiple vascular channels, generating a multifocal cribriform appearance with extension to the bone and areas of necrosis (Figure ). Bone tissue with marrow and malignant tumor with formation of vascular channels and soft tissue were composed by skeletal muscle without alterations (Figure ). Bone spicules were focally infiltrated by malignant vascular neoplasia with dense connective tissue and adipose tissue without tumor (Figure ). Histopathological diagnosis of grade 2 epithelioid angiosarcoma with focal infiltration to C6-C7 lamina was made. The patient showed marked improvement 48 hours postoperatively with strength 5/5 of upper and lower limbs, patellar and Achilles reflex (2+), <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 37-year-old gravida 4 woman underwent laparoscopic radical hysterectomy with pelvic and paraaortic lymph node resection for cervical cancer Ib2. The body mass index of patient was 22.3 kg/m2, and she had no medical history of vascular disease, hypertension and diabetes mellitus. The patient had smoked a half of pack per day for 15 years. She was placed in the lithotomy position during operation, and the intermittent pneumatic compression device was placed on the lower extremities. The operation lasted 6 hours 45 minutes under general anesthesia. The patients' vital sign was stable throughout the operation. The estimated blood loss was 300 mL and hemoglobin level was 13.2 g/dL at the beginning of the operation and 11.8 g/dL postoperatively. During operation, there was no specific finding. In the recovery room after surgery, the patient complained of pain, tenderness, and numbness in left lower leg, and the numeric rating scale for pain was 9 points. However, pulsation of the dorsal arteries of the feet was confirmed. Then computed tomography venography for evaluation of deep vein thrombosis was performed, and revealed low attenuation and suggested decreased perfusion in left calf muscle. However, there was no evidence of deep vein thrombosis in both legs (). Then using the analgesics such as non-steroidal anti-inflammatory drugs, pethidine and patient controlled analgesia, the numeric rating scale was reduced from 9 to 2 points. The patient was admitted to the intensive care unit for closed observation without any procedure. On the first postoperative day, left lower leg pain was persistent. Computed tomography angiography for evaluation of lower extremity thromboembolism was performed. Computed tomography angiography revealed thrombotic total occlusion at mid to distal left external iliac artery (); and serum creatine phosphokinase value was elevated up to 9,844 U/L (normal range, 43 to 165 U/L). Immediate thrombectomy was conducted by th", "role": "user" }, { "content": " e radiologist in the angiographic intervention room. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 41-year-old woman was hospitalized for a left thyroid mass, which had been found using type B ultrasonography. There was no enlargement of the lymph nodes in the neck on physical examination, and the color of the skin surface was normal. The mass was located in the left lobe of the thyroid, with an irregular shape, which indicated a malignant tumor. The maximum diameter of the mass was 2.4 cm, detected by ultrasonic examination. Scattered clusters of atypical cohesive epithelioid cells were found in the mass of the thyroid by fine-needle aspiration. The hematoxylin-eosin staining of the specimen, together with frozen section and extensive immunohistochemistry, confirmed a diagnosis of paraganglioma of the thyroid gland with melanocytic differential. The patient underwent a mass excision, and no lesion was found using computed tomography or magnetic resonance imaging. Four lymph nodes, which showed no metastatic carcinoma (0 of 4), were isolated from the left neck.\nThe mass specimen was measured to be 3.5 cm × 2.3 cm × 2.0 cm. On the cut surface, all the visible area of the tumor was solid without cyst changes, with grayish white or black color, and the margins of the tumor were slightly irregular. Two distinct components were found in the black area of the tumor through microscopic observation. The first component, the majority of the mass, was composed of solid sheets and clusters of cohesive epithelial cells, with no pigment observed in the cytoplasm (, ). The second component comprised cells covered by pigment, with the intercellular substance and structure unclear (, ). The tumor cells in the first component were arranged in a nest-like distribution without any gland cavity. The tumor consisted of monotonous sheets of cells with fluent and light-dyed cytoplasm, but without significant atypia. Tumor cells were round or polygonal, and the cytoplasm was basophilic. No mitotic figure was observed. The", "role": "user" }, { "content": " re was no tumor thrombus observed in the vascular tissue after multiple dissections. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 2-year-old female child was brought to our institute with swelling beneath the tongue. The swelling was present since birth, which was of peanut size and increased to the present size in the last 2 months []. The child had difficulty in having food and also had breathlessness.\nOn examination, a single swelling was seen in the floor of the mouth, measuring approximately 4 × 3 × 2 cm. The mucosa over the swelling was red in color and showed a bluish hue. The consistency of the swelling was soft and the borders were regular. The surface was smooth and nonulcerated. There was no pain or tenderness. Radiological findings showed no abnormality. The CT scan findings revealed a well-defined cystic lesion of approximately 4.9 × 3.1 × 3 cm in floor of the mouth with a small locule extending posteriorly and compromising anterior pharyngeal space []. There was no evidence of cervical lymphadenopathy nor did the swelling show any relation with the thyroid gland. Based on the above findings, a clinical diagnosis of ranula was given and surgical excision was planned. Hematological investigations were done and the results were in normal limits. Chest X-ray showed clear lung fields and normal cardiac size and configuration. An intraoral approach was taken for the surgical excision of the lesion.\nThe swelling was excised completely and sent for histopathological examination. On gross examination, the lesional tissue was creamish brown in color ", "role": "user" }, { "content": " and measured 4 × 3 × 1.8 cm in size, it <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 62-year-old male presented to our outpatient department with painless swelling of both his shoulders and restricted movements of the bilateral shoulder joints. His condition began when he was approximately 35 years old and he started experiencing reduced sensation in the bilateral upper limbs. No medical treatment was taken and the patient went to some osteopath who gave him some oil for local application. Patient condition did not improve and he started experiencing reduced sensations in the bilateral lower limbs. Despite that, he did not seek medical attention and his condition gradually worsened. There was no history of significant trauma in the past. Physical examination revealed generalized swelling about the shoulder, more on the left side []. On the right side, there was abnormal motion, distal to where the shoulder joint would be expected . On the other hand, the left shoulder joint was found to be dislocated, with humeral head anterior to glenoid cavity, leading to significant restricted joint movement. On palpation, the shoulder joints were nontender. Bilateral shoulder movements were restricted. Active forward flexion was 40 on the right and 30 on the left side, abduction 30 on the left and 25 on the right side and internal rotation bilaterally up to the sacrum. He had 4/5 shoulder abductor strength and 4/5 shoulder flexor and extensor strength bilaterally. Range of motion for passive movements was significantly higher than on active movements, more on the right side. Passive movement was painful on terminal range of motions. His biceps strength was 4/5, triceps strength was 5/5 while motor strength in bilateral distal extremities was 5/5. There was decreased sensation involving the entire upper extremities bilaterally and healed trophic ulcers found on the fingers and dorsal and ulnar border of the hand and forearm . The biceps, triceps and brachioradialis reflex were absent. There was muscle wasting in both upper limbs.\nPatient was worked up and X-ray, complete blood counts,erythrocyte sedimentation rate,fasting blood sugar,venereal disease research laborato", "role": "user" }, { "content": " ry <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 35-year-old female was referred to our department because of a breast nodule in the upper right region. One year earlier, she had been diagnosed with stage IV B mediastinal large B-cell lymphoma. Subsequently the patient was treated with high-dose sequential (HDS) chemotherapy, followed by an autologous stem-cell transplantation with complete remission. The HDS is a comprehensive program including an initial debulking with two APO, two DHAP, and an high chemotherapy phase with PBPC harvesting followed by an autologous stem cell transplantation []. Initial investigations included a computed tomography scans of the abdome", "role": "user" }, { "content": " n, thorax, and pelvis which failed to detect any further abnormality, a whole body positron emission tomography using 18F-fluorodeoxyglucose (FDG-PET) showed a positive uptake of radiotracer in the right breast suggesting a recurrent disease (). On examination a firm, slightly mobile mass with skin thickening was palpated in the upper outer right quadrant, no enlarged lymph nodes were found in the right axillary region, no other significant physical examination findings were noted. A mammography revealed a solitary ill-defined mass in the upper outer quadrant of the right breast. The lesion was surgically removed. At light microscopy, a tumoral growth which diffusely infiltrated the mammary gland consisting mainly of blasts with variably shaped nuclei, multiple evident nucleoli, a rather dense chromatin and a moderate amount of cytoplasm was demonstrated (). Surprisingly, immunohistochemistry showed that the neoplastic cells were strongly stained for CD34 () and myeloperoxidase, being negative for the remaining cell markers employed CD79a, CD20, CD10, CD3, and Glycophorin A. Based on morphologic and phenotypic findings a diagnosis of myeloid sarcoma was made. Following the histological diagnosis of acute myeloproliferative disorder, the patient underwent extensive laboratory investigations which showed normal red blood cell, white blood cell, and platelet counts with no blasts in the peripheral blood. Bone marrow aspirates and trephine biopsies displayed neither significant abnormalities nor evidence of leukemic infiltration and a normal karyotype. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 51-year-old male was diagnosed with muscle-invasive urothelial cell carcinoma in May 2015. Standard neoadjuvant chemotherapy was given followed by radical cystoprostatectomy. Final pathology showed pT3 N0 M0, stage III disease. He remained disease free until April 2016, at which point he developed new exertional dyspnea and a small lung nodule was noted on imaging. During cardiac clearance for a biopsy, a Mobitz 2 heart block with bradycardia was noted. Transthoracic echocardiogram (ECG) demonstrated a mass in the right ventricular outflow tract, which was additionally found to be fluorodeoxyglucose (FDG)-avid on positron emission tomography (PET) computed tomography (CT) (Figure , upper panel).\nThe patient developed progressive dyspnea with minimal exertion and then experienced a syncopal episode prompting hospitalization. Biopsy of the right ventricular mass demonstrated poorly differentiated carcinoma, consistent with urothelial origin (Figure ).\nThe mass was not felt to be respectable and chemotherapy was not felt to offer rapid disease control in the setting of progressive symptoms. He was offered palliative radiotherapy. His bradycardia progressed to a complete heart block, likely due to the growth of the mass, necessitating placement of a dual chamber pacemaker. The right ventricle mass was treated with 45 Gy in 18 fractions (3D conformal photons for 5 fractions, followed by intensity-modulated radiotherapy for t", "role": "user" }, { "content": " he remaining 13 fractions (to reduce dose to the left ventricle). Figure <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 44-year-old female patient was admitted to our clinic in 2012 with left shoulder pain which had been present for 1 year. Past medical history revealed that she had been examined at a state hospital in her hometown 9 months previously with complaints of shoulder pain. After magnetic resonance imaging (MRI) examination, a preliminary diagnosis was made of malignant mass in the shoulder joint. A tru-cut biopsy was performed, after which she underwent surgery for aggressive fibromatosis. Despite radiotherapy treatment for 6 months after surgery, her condition gradually worsened. During follow-up, an MRI study was carried out for susp", "role": "user" }, { "content": " ected recurrences and, as a result, she was referred to our hospital <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 11-year-old Indian girl presented with a history of recurrent non-healing left leg venous ulcers associated with swelling of the involved limb. There was no associated erythema and her leg was non-tender. There was no history of trauma. There was ", "role": "user" }, { "content": " no significant antenatal history in her mother and our patient was delivered normally at a local hospital with an uneventful postnatal period. There was no history of umbilical cannulation, cardiac catheterization, or any other femoral intervention. She had reported these symptoms since early childhood but no medical evaluation was done in the past. There were no other complaints.\nHer physical examination was remarkable for large venous collaterals on her anterior abdominal wall with flow from below upwards (Fig. ). She was also noted to have swelling and multiple venous ulcers on her left lower limb (Fig. ). Both lower limbs had varicose veins. There was no calf tenderness. There was pedal edema on her left lower limb. The rest of her examination was normal.\nOn color Doppler examination, her infrarenal IVC as well as her bilateral internal and external iliac veins were not visualized. A short segment of her proximal right common femoral vein and proximal superficial femoral vein were faintly visualized. Her left-sided common femoral, superficial femoral, and popliteal veins were not visualized.\nA computed tomography (CT) venogram done to define her venous anatomy showed absence of infrarenal IVC as well as absence of bilateral common iliac and left common femoral veins (Fig. ). A short segment of her right common femoral vein was seen with collaterals draining into her anterior abdominal wall. Her venous system at the level of the renal vein and above was normally developed (Fig. ). There were well-developed collaterals over her anterior abdominal wall and in her bilateral lower limbs. The superficial venous system of her bilateral lower limbs was well developed and draining from collaterals.\nEchocardiography showed normal cardiac anatomy and function.\nWith symptomatic treatment, her venous ulcers improved. There were no surgical or interventional therapies possible <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 36-year-old married female having two children, both delivered by caesarian section, presented to us with complaints of urinary frequency, urgency, and urge incontinence associated with low-grade fever. She had history of recurrent urinary tract infections (UTI) since childhood and had received multiple courses of antibiotics. She had been diagnosed as having a persistent cloaca and had undergone multiple cutback procedures at birth. On pelvic examination, a single short common channel opening in the perineum was found. All preoperative blood investigations including renal function were normal.\nUltrasound abdomen showed a mass lesion in urinary bladder []. Computed tomography (CT) abdomen and pelvis with three dimensional reconstruction confirmed the presence of persistent cloaca, a large mass in the bladder with infiltration into the pubic bones [] with uterus didelphys and rectum crossing between the two uteri and opening into the bladder base []. Cystoscopy revealed a large solid, sessile growth arising from dome and anterior wall of urinary bladder, rectum opening just distal to bladder neck and two cervical openings posteriorly. Cold cup biopsy from growth revealed a moderately differentiated squamous cell carcinoma (SCC).\nWith a diagnosis of squamous tumor with persistent cloaca, radical cystectomy and urinary diversion were planned. Intraoperatively, we found a 15 cm pouch colon along with a large tumor involving anterior wall of bladder, infiltrating the pubic bones. Two uteri were lying ", "role": "user" }, { "content": " on either side of the bladder []. Pelvic exenteration, standard bilateral pelvic lymph node dissection, pubectomy, and wet colostomy were performed. Operative time was 6 hours with 1200 cc blood loss and the patient received 2 units of packed cell transfusion. Postoperative course was uneventful except for a small incision disruption which was managed with secondary suturing. Histopathologic findings confirmed the presence of squamous cell carcinoma. Resected margins were free of tumor and 50% of pelvic nodes showed tumor metastases. She was started on adjuvant methotrexate and platin-based combination chemotherapy but finally lost to follow up <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 45-year-old, gravida zero para zero, female presented with a one-week history of a fluctuant mass and erythema in the right superior breast. She had a history of seat belt injury to the right breast seven years prior, and had felt stable masses in the breast for two years prior to presentation. After admission to the hospital, intravenous antibiotic therapy was initiated for symptoms of infection. No family history of breast cancer was noted at that time. The work-up for presumed mastitis began with a bilateral diagnostic mammogram. The provided patient history included a possible diagnosis of cellulitis with imaging to rule out an abscess of the right breast. The ordering physician also emphasized the history of seat belt injury. The admission diagnostic mammogram revealed heterogeneously dense breasts, as well as the presence of fat necrosis in the upper outer quadrant of the right breast at the 12 o’clock position (Figure ).\nNo significant masses, calcifications, or abnormalities were noted in the left breast at that time. Ultrasound of the r", "role": "user" }, { "content": " ight breast demonstrated edema with no evidence of malignancy. The patient was diagnosed with cellulitis of the right breast and discharged with antibiotics.\nTwo weeks later, the same patient returned with exacerbated erythema, hardness, and tenderness in the right breast. In addition, she also noted a new lump in her left breast which she had not noticed before and mentioned this for the first time to the radiologist while ultrasound is being performed on the right side. The right breast showed redness, induration, and tenderness in the upper outer quadrant. Subsequent diagnostic ultrasound of the left breast revealed an irregularly shaped hypoechoic mass with microlobulated margins. The mass measured 21 x 18 x 14 mm and was located at the 3 o’clock position, 3 cm from the nipple (Figure ).\nUltrasonography of the right breast revealed only fat necrosis and edema consistent with the patient history. Overall, the imaging was given a BI-RADS assessment <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 38-year-old female patient came with a chief complaint of difficulty standing up from squatting position since 2 years ago. The patient also suffered heaviness and numbness from her hips that radiated to both of her knees and ankles. The symptoms worsened steadily in the past 4 months with both lower limbs getting weaker. Laboratory results came out normal, with no signs of infection or positive tumor markers. Radiological examination showed no apparent abnormalities as well. An MRI was obtained, and a tumor mass in the intradural region level of T10–T12 was found (). At that time, the patient was offered surgery, but she chose to undergo treatment with a bone setter. Around two months later, the patient returned to hospital with profound weakness on her lower extremity. Her physical examination revealed paresis from her thigh on both lower extremities grade 1-2/5 power in left and right lower limbs, respectively. Increased patellar reflexes were found on both limbs. Another MRI was performed and showed that the mass had grown to lumbar vertebrae L2, accompanied with worsening of the neurological statuses and impaired sensibility, as well as defecating and urinating problems (). From the history, spinal manipulation procedure was performed by a bone setter, although no specific techniques were available for review.\nA surgical procedure was proposed for exploration and decompression to the patient. The operation started by opening the lamina on T10–T12 levels, followed with laminectomy and hemostatic procedure to stop the bleeding, until the dura was exposed (). A dense mass from T10 to T12 was palpable from the dura layer. After we exposed the lamina, we observed that the dura was tense from touch, and a solid mass underneath the dura was palpable from T10 to L2. Intradural tumor excision was performed by a sharp 3 mm incision in the midline of the dura and then continued with blunt dissec", "role": "user" }, { "content": " tion, <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 17-year-old girl, weighing 50 kg with a history of delayed", "role": "user" }, { "content": " developmental milestones, had presented with a right frontal <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 21-year-old male sustained a single gunshot wound with entry over the left scapula. At the scene, the emergency medical response personnel found him on the ground alert, unable to move his legs, and noting pain all over his body. He was hemodynamically stable in the field. Ground ambulance immobilized the neck with a cervical collar and brought him to a local level 1 trauma center. At arrival to the trauma bay, he had a Glasgow coma scale score of 15. He was primarily complaining of bilateral hand numbness. On further examination, he had no motor or sensory function present in the lower extremities. In the upper extremities, sensation was present but diminished from T1 and above, with no sensation below T1. Motor function in the upper extremities was graded 3 (based on ASIA impairment scale) in all the key muscles on the right and only grade 2 on the left in the deltoid and biceps muscles with no motor further distal. Next, he was taken to the computed tomography (CT) suite for imaging of the head, neck, and thorax. Imaging, from the CT scan, revealed bullet tract through the posterior lateral left upper hemithorax, left scapular body, left lung apex, and base of left neck with bullet fragments terminating in the C6 vertebral body. Initial studies showed no acute intracranial abnormalities; however, there were fractures of the left C5 and C7 transverse foramina and processes and left C6 vertebral body and lamina fractures with bony and bullet fragments in the left aspect of the spinal canal at the C6 level (). As a result, there was a dense left epidural hematoma within", "role": "user" }, { "content": " the spinal canal at C2 through C7 levels. At the time, CT neck angiogram showed that the left extracranial <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 29", "role": "user" }, { "content": " years old female with no comorbidities developed insidious onset gradually progressive pains in the right upper extremity along C5 dermatomal distribution which was soon followed by weakness in right-sided grip. She underwent imaging and was found to have a mass lesion in the cervical spine at C4 level. The radiological appearance of the lesion was suggestive of intradural extramedullary (IDEM) pathology, for which she underwent surgery at an outside hospital. As per her operative notes, near total excision was achieved. Preoperative magnetic resonance imaging [MRI] was not available with the patient.\nHistopathology report was suggestive of a pigmented nerve sheath tumor. No immunohistochemistry was performed at the time.\nSoon after her surgery, she had relief from pains but weakness persisted. Over the next 2 months, she developed worsening of heaviness in the right upper limb which progressed to lower limb over next fortnight and then to left upper and lower limbs over the next 1 month. There was rapid worsening of quadriparesis.\nOn examination, her higher functions and cranial nerve examination were found to be normal. She had spastic grip in the right upper limb. Power was Grade I in right wrist extensors as well as flexors. Grade II at elbow flexors, Grade II at right elbow extensors, and Grade II power at right deltoid and shoulder abductors. Left upper and lower limbs had Grade IV power. There was loss of pain and crude touch sensations over the left half of the body in graded manner below C4 dermatome. She also had diminished bilateral biceps reflexes. Triceps reflex was brisk. There was bilateral ankle and patellar clonus, and plantars were mute. Joint position sense was lost all over.\nOn imaging, MRI showed homogeneously enhancing IDEM mass lesion at C4/5 level with extension into the right C4 neural foramina causing widening of the foramen. The lesion appeared like a dumbbell with the outer component anterior to <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 46-year-old female with a known history of hypothyroidism for 10 years presented in the outpatient department with dry cough for one week, fever for two days and breathlessness for 10 days which has worsened over the last two days. She had no history of power loss in any of her limbs. She had no history of smoking. She had no family history of any autoimmune disorders.\nShe visited a primary care physician one day earlier and was recommended arterial blood gas evaluation to detect the degree of respiratory impairment and possible etiologies. The arterial blood gas analysis report showed a pH of 7.3, pCO2 of 60 mmHg, pO2 of 52 mmHg and the patient was advised admission considering a high level of pCO2. On admission, blood samples were drawn for complete blood count, renal function test, liver function test, and thyroid stimulating hormone; all of which showed normal results. To rule out the pulmonary thromboembolism, a cardiothoracic pulmonary angiogram was performed which showed posterobasal consolidation in both lower lobes with a thin rim of pleural effusion bilaterally and a few enlarged homogeneously enhancing lymph nodes in the perivascular and right paratracheal regions.\nOn admission, the patient was also started on non-invasive positive pressure ventilation, bronchodilators, and broad-spectrum antibiotics against pneumonia. Despite these interventions, the patient showed no improvement for the next 24 hours. The subsequent arterial blood gas analysis showed a pH of 7.2 with pCO2 of 105 mmHg. Breath holding counts decreased from 12 to 6, thus developing hypercapnia. In addition, the patient started developing drowsiness for which a neurology consultation was ordered to rule out other neurologic causes of type 2 respiratory failure. To rule out myasthenia gravis, various serological tests were performed including acetylcholine receptor antibodies, IgA antibodies, electromyography with the re", "role": "user" }, { "content": " sults expected to arrive the next day.\nOwing to the expected delay in the results, a bedside ice pack test was performed to diagnose myasthenia gravis. A positive response was elicited with the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A female patient aged 18 years presented with a swelling over the left ear of 1-year duration associated with decreased hearing. Clinical examination revealed a soft swelling measuring about 2 cm × 2 cm obliterating the concha of the left ear and the external auditory canal []. Similarly, there was another soft swelling of 3 cm × 2 cm in the retroauricular region completely obliterating the retroauricular groove []. There were multiple cafe au lait macules of varying sizes over the body. There was also a diffuse thyroid swelling involving both the lobes with no apparent nodularity. On subjecting the patient to slit-lamp examination, there were multiple Lisch nodules over both the irises. Tuning fork tests revealed mild conductive hearing loss in the left ear. Fine-needle aspiration cytology (FNAC) of the thyroid swelling showed features suggestive of Hashimoto thyroiditis [].\nThe mother of the patient had a large swelling over the right upper eyelid that co", "role": "user" }, { "content": " mpletely obscured her vision []. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 53-year-old male patient with a history of stage C colon cancer complained of painless diminution of vision in his right eye of acute onset and stationary course for 3 days. He underwent a hemicolectomy for his colon cancer 5 months before and had been receiving chemotherapy in the form of 5-fluorouracil, oxaliplatin, and folinic acid every 2 weeks for 4 months. He had a past medical history of hypertension, which was controlled by medication. He had no previous history of ocular problems.\nExamination revealed a corrected distance visual acuity of 20/ 400 in the right eye and 20/ 80 in the left. Color vision was 2/ 10 in the right eye and 10/ 10 in the left using Ishihara plates. Examination of the pupil revealed a right relative afferent pupillary defect. Intraocular pressure was 16 mmHg in both eyes. Extraocular motility was full. Anterior segment examination revealed nuclear cataract in both eyes. Fundus examination showed bilateral optic disc elevation with multiple superficial nodular swellings over both optic discs. There were also multiple flame-shaped hemorrhages over the right optic nerve head with an anomalous left retinal vasculature (\n).\nA computed tomography scan of the brain and orbit was performed which revealed no cerebral pathology but suggested the presence of bilateral ODD more on the left side (\n).\nRight NAION on top of bilateral ODD was suspected and fundus fluorescein angiography was subsequently performed to confirm the diagnosis (\n).\nB scan ultrasonography was also performed to confirm the presence of ODD and revealed bilateral buried drusen (\n). Visual field testing revealed an altitudinal field defect in the right eye involving the inferior hemifield. A final diagnosis of bilateral ODD with right NAION was made and diminution of vision in the le", "role": "user" }, { "content": " ft eye was attributed to the presence of nuclear cataract <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "We present a case of a 25 year-old man who complained of worsening back pain and left lower limb weakness and radiculopathy for two weeks. He was unable to walk due to the pain and weakness. There was no bowel or bladder incontinence but he had loss of appetite and significant weight loss.\nHe had history of fall and sustained a stable burst fracture of T12. He was treated with an extension body cast at that time as there was no suspicious lesion on the radiographs. During follow-up, he developed a kyphotic deformity of which we performed pedicle subtraction osteotomy of T12 a year after the primary injury. He defaulted the follow-up after surgery.\nExamination revealed a posterior midline surgical scar measuring 12cm. There was a mild kyphotic deformity. His hip and knee flexion were weak with a medical research council (MRC) muscle power grading of 3. The ankle and toes had MRC muscle power grading of zero. Magnetic resonance imaging (MRI) was suggestive of an aggressive spinal tumour over T12 with extension to T11 and L1 (). Computed tomograph", "role": "user" }, { "content": " y of the lungs revealed no lung metastasis. He underwent posterior extension of fusion from T8-L4 with total <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 57-year-old man was evaluated in the emergency room (ER) of our hospital for complains of dizziness and near syncope while walking home earlier that day. He had started feeling generalized weakness and fatigue after he underwent neck surgery for a tonsillar lesion at another hospital 6 months earlier. He also reported unintentional weight loss of 20 pounds over 6 months along with loss of appetite. He denied any loss of consciousness, palpitation, shortness of breath, chest pain, hearing difficulty, headache, vision changes, nausea, vomiting, diaphoresis or fever. He had human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) with a CD4 count of less than 20. He was non-adherent t", "role": "user" }, { "content": " o the anti-retroviral therapy. He also had chronic obstructive pulmonary disease and was using albuterol and steroid inhalers. His social <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 38-year-old Indian woman reported to the Department of Periodontics, Government Dental College and Hospital, Hyderabad, India in July 2011 with a chief complaint of burning sensation and itching in relation to mandibular anterior lingual gingiva for past 1 month. Patient had provided informed consent to be profiled. Past dental history revealed that the patient had visited a couple of private general dental practitioners where the lesion was misdiagnosed as an aphthous ulcer and palliative care was provided for the same. As there was no improvement in her complaint, she decided to come to the dental school for an additional opinion. She was referred for diagnosis and treatment in post-graduate periodontics clinic. There was no contributing medical or family history except that the patient had undergone hysterectomy and appendectomy 10 years back. Patient was in good health and denied any deleterious habits like smoking, alcohol consumption or recreational drug use. No lymph nodes were palpable or tender in a head and neck examination.\nIntraoral examination revealed a clean mouth with good gingival health and minimal deposits with the full complement of teeth. Clinical examination of the lingual gingiva revealed a 1 cm × 1 cm ulcer extending mesiodistally from mid lingual surface of 41 to mesiolingual surface of 43 and corono-apically from the gingival margin to the floor of the mouth, not extending beyond the anterior part of lingual frenum. The surface of the lesion appeared to be ulcerated and pebbly with isolated areas of erythema and had well-defined borders that were found to be in level with the adjacent tissue. The ulcerated part of the lesion had rhomboid appearance. The surface of lesion toward the lingual frenum appeared to have a shaggy base covered with slough and there was no exudation []. Intraoral periapical X-ray showed bone loss extending u", "role": "user" }, { "content": " p to the apical 3rd in relation to 41, 42 []. Since the clinical findings of the existing lesion didn’t correlate with any <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "In 2006, a 38-year-old man was ejected from the bed of a pickup truck and transferred to a level one trauma center for the evaluation and treatment of a complex pelvic fracture. A suprapubic catheter was placed prior to transfer due to a suspected severe urethral injury. The patient had no significant past medical history.\nOn arrival, the patient was tachycardic but normotensive and oxygenating adequately on room air. The physical exam was pertinent for an unstable pelvis and a digital rectal exam that revealed a foreign body in the rectal vault. There was normal rectal tone. The remainder of the exam revealed lacerations to the bilateral lower extremities with ecchymoses to the bilateral hips. Computed tomography (CT) evaluation revealed an intraperitoneal bladder rupture, a complex pelvic fracture involving the right sacroiliac joint, a shattered right acetabulum, a complete right femoral neck fracture, and the femoral head lodged in the pelvis (Figure ).\nThe patient was taken to the operating room for an exploratory laparotomy and anoscopy. Anoscopy confirmed the femoral head was within the rectal vault with severe disruption of the right lateral rectum. The femoral head was removed from the rectum transanally, and the rectum was thoroughly irrigated. The bladder was repaired.\nThe rectum and perirectal space were noted to have significant hematoma and fecal contamination that communicated with the acetabular fracture. Intraoperatively, the patient became critically ill, and the procedure was abbreviated. A temporary abdominal closure was placed, and the patient was taken to the intensive care unit for resuscitation. The patient returned to the operating room in 24 hours for fecal diversion and further debridement, irrigation, and drainage of the right perirectal space. Despite daily operative washouts, right hip disarticulation was ultimately required to achieve adequate debridement and sepsis control. After prolonged hospitalization, the patient was transferred to a long-term care faci", "role": "user" }, { "content": " lity out of state, which was closer <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 49-year-old man, an amateur long-distance runner for 10 years, healthy and with no history of diseases, with positive results of periodic health examinations, had been suffering only from frequent headaches of unknown organic cause since early childhood. He had not suffered from any significant cardiac diseases apart from arrhythmia (single supraventricular extrasystoles) that did not require any medical treatment. Three months prior to the episode he had had his periodic exercise ECG, echocardiogram and Holter-ECG performed. None of them showed any contraindications for practising sport. Family history did not indicate any risk of vascular diseases either. After 3 h of the marathon race the patient started suffering binocular visual impairment in the form of flash lights variably narrowing his visual field. It was not accompanied by any other symptoms, neurological complaints or pain. The patient thought these symptoms were functional disorders caused by exhaustion and dehydration, so he only slowed down and finished the race. He did not suspect that this symptom might be caused by any trauma. After 2 h of rest the symptoms resolved spontaneously. After another 2 h the patient headed to the Accident and Emergency Department, where he underwent observation and was consulted by the neurologist, who did ", "role": "user" }, { "content": " not recognize any abnormalities. He was also examined by the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The patient was treated with Adriamycin 25 mg Cis-platinum 40 mg preceded by Mannitol 12.5 grams intravenous bolus and Zofran 11 mg on two occ", "role": "user" }, { "content": " asions given as an antiemetic . The chemotherapy was well tolerated . DOCTORS DISCHARGE <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The second case involves a 30-year-old Deaf, Hispanic male who presented to the Emergency Department after his mother reported that the he was behaving oddly and not taking his risperidone. Per reports, the patient was talking to his mother about going places in a UFO and exhibiting", "role": "user" }, { "content": " disorganized and illogical behaviors. He was subsequently placed under a Baker Act by the emergency room physician who documented <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 57-year-old woman with a history of hypertension, diabetes, hyperlipidemia, and cigarette smoking presented with an acute myocardial infarction. She underwent successful stent placement in the left anterior descending coronary artery using femoral artery access. During her initial hospitalization, she also reported lifestyle-limiting left leg claudication, and right arm heaviness and weakness exacerbated by movement. She reported no focal neurologic symptoms and had no dysphagia. Left arm blood pressure was 130/90 mm Hg and right arm blood pressure was 80/60 mm Hg. Left dorsalis pedis and posterior tibial pulses were not palpable. She returned 2 weeks later and underwent stent placement for a 95% stenosis of the left common iliac artery. Because right subclavian artery disease was also suspected based on arm symptoms and discordant arm blood pressures, arch aortography was performed at that time, demonstrating the stump of an occluded ARSA ( and ). Delayed imaging demonstrated collateral flow opacifying the distal vessel after a 60-mm occluded segment (). The right vertebral artery originated from the right common carotid artery. Duplex ultrasound showed monophasic flow in the right subclavian artery with spectral broadening and a peak systolic velocity of 55 cm/s. After a discussion of therapeutic options for ARSA, the patient chose conservative therapy rather than surgery or percutaneous treatment. She was treated with aspirin, clopidogrel, and atorvastatin.\nDuring routine follow-up, the patient continued to report exertional right arm pain, heaviness, and weaknes", "role": "user" }, { "content": " s. Two and a half years <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 20-year-old female patient was referred to our hospital with abdomina", "role": "user" }, { "content": " l pain, nausea <\|endoftext\|>", "role": "assistant" } ]

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