Split (2)

train · 166k rows

messages listlengths 2 2
[ { "content": "A 35-year-old Caucasian female with extensive history of pelvic surgery but without prior urological history underwent robotic-assisted laparoscopic excision of endometriosis by gynecological surgery team secondary to chronic pelvic pain with suspected endometriosis. On initial laparoscopic evaluation of pelvic contents, visible vermiculation of bilateral ureters was noted as well as suspected findings of endometriosis-like lesions covering the pelvic peritoneum. The pelvic peritoneum was excised with sparing of the urinary bladder. Careful ureterolysis was performed bilaterally, during which the distal left ureter was found to be partially denuded, spanning 2 cm in length (). An intraoperative urologic consultation was requested, and denuded ureteral injury was confirmed by urology o", "role": "user" }, { "content": " n laparoscopic evaluation. Given no evidence of ureteral laceration or obvious extravasation of urine from left ureter, no cystoscopy or <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The patient was an 18-year-old Japanese woman with no relevant medical history. Figure shows the course of her body weight, which had been around 44 kg until disease onset. Her weight loss started when she was 16 years old. She was diagnosed with an eating disorder and also presented with SMA syndrome, which seemed to be caused by weight loss due to the eating disorder because no other organic abnormality was present. The patient received conservative nutrition therapy at a hospital located in her residential area when she was 17 years old. The treatment initially improved her weight, but she ceased treatment due to dissatisfaction with the patient–doctor relationship, and her weight loss resumed.\nThe patient reported that abdominal symptoms due to SMA syndrome, such as abdominal distension and vomiting, resulted in weight loss. She desired to undergo surgery for SMA syndrome, and found on the internet a distant hospital that performed surgery for SMA syndrome. However, after undergoing laparoscopic duodenojejunostomy, her body weight did not improve during the six months after the surgery. When she was 18 years old, she arrived at our center, the University of Tokyo Hospital, with a chief complaint of weight loss. She was immediately hospitalized due to severe malnutrition.\nAt hospitalization, her height and weight were 159.1 cm and 27.5 kg, respectively (i.e., body mass index [BMI] of 10.9). She was diagnosed with anorexia nervosa binge-eating/purging type (ANBP) according to the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition []. Notably, her vomiting, which had been considered a symptom of SMA syndrome before surgery, did not improve after surgery. Therefore, her vomiting could have been a symptom of ANBP, while she initially concealed her self-induced vomiting from us and only revealed it six months after the initial visit to our hospital.\nAfter hospitalization, conservative treatment, including dietary ", "role": "user" }, { "content": " nutrition and central venous nutrition, <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The patient is a 57-year-old nulligravid female who presented to clinic with symptoms of urinary urgency incontinence. She had a past medical history of endometriosis, autoimmune hepatitis, cirrhosis, and denied any pertinent mental/psychological history or trauma. Her initial symptoms included urgency, voiding up to 5 times an hour, and nocturia up to five times per night. She had no previous vaginal surgeries. Baseline sexual function evaluation was completed at intake with the Female Sexual Function Index (FSFI) questionnaire where the arousal domain equaled 0.9 (range 0-6, with 6 indicating maximal arousal) (). Pelvic examination was significant for vaginal atrop", "role": "user" }, { "content": " hy but no notable clitoral or labial abnormalities were visualized. There were <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 10-month-old girl, with no past history of medical or surgical illness, presented to the emergency department (ED) with fever, altered m", "role": "user" }, { "content": " entation, vomiting, and loose stools. The fever was continuous and had a duration of one week, measured by the tympanic route, with a maximum temperature of 38.5 °C responding to antipyretics. It was associated with minimal symptoms of coryza, which resolved over the course of the fever. There were no associated rashes, night sweats, or weight loss according to the parents. She was assessed four days prior to her ED visit at a private clinic; they prescribed azithromycin for one week but the fever showed no signs of remission. A day later, three days prior to presentation, she started vomiting after each feed. She vomited at a frequency of six times per day, and it primarily consisted of food content. She also had loose stools occurring three times per day; it had mucus but no blood was observed. She had no associated abdominal pain or jaundice at the time of presentation. A day prior to her ED visit, her parents noted a change in her level of consciousness associated with decreased feeding and activity. There were no perceived motor or sensory impairments and no other neurological deficits. She is the product of a full-term uneventful pregnancy and was thriving well on bottle feeding and diet for age. The patient was vaccinated up to her age per the national vaccination schedule.\nDuring her initial physical evaluation, the patient was febrile at 38.9 ° C, with an elevated heart rate of 190 per minute and an elevated respiratory rate of 42 per minute. Upon inspection, she looked lethargic, lying on the bed with minimal activity, and she exhibited a Kussmaul breathing pattern. There were signs of moderate dehydration, such as pallor, mottled skin, and depressed fontanelle; otherwise, the physical examination was unremarkable. Initial investigations conducted at the ED have been <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 60-year-old male was diagnosed with histologically confirmed glomerulonephritis secondary to anti-neutrophil cytoplasmic antibody -positive microscopic polyangiitis, following investigations for elevated creatinine on routine blood test. He was treated in hospital with intravenous methylprednisolone (500 mg daily) and oral cyclophosphamide (100 mg daily) for three days. He was discharged home on a weaning course of prednisolone and cyclophosphamide, with normalisation of his renal function.\nTwo weeks following this admission, the patient was admitted to a regional hospital with a two day history of nausea, vomiting and diarrhea with intolerance of oral intake. His wife had had similar symptoms recently. The patient developed large volume watery diarrhea, up to eight liters per day. He required transfer to a tertiary hospital intensive care unit where he received hemofiltration for hypovolemic acute kidney injury. Cyclophosphamide was initially reduced to 50 mg daily and then ceased in setting of potential infectious pathology. The patient had received approximately one month of cyclophosphamide, up to 2.1 g of total dose. Empiric antimicrobial therapy was commenced including tazobactam and piperacillin, intravenous metronidazole and ganciclovir. His stool specimen showed secretory diarrhoea with no infective agents identified. Vasoactive intestinal polypeptide and chromogranin levels were also non-diagnostic.\nSerial computed tomographs of his abdomen revealed diffuse mural thickening of the small and large bowel. Upper and lower endoscopic evaluations demonstrated denuded and erythematous mucosa in the duodenum, as well as from sigmoid colon to t", "role": "user" }, { "content": " erminal ileum with no significant interval change in macroscopic appearance (Figure ). The rectum was relatively spared. Histopathology showed full thickness mucosal ulceration and inflammation throughout the terminal ileum and large bowel (Figure ). There were no features of inflammatory bowel disease, vasculitis or viral inclusions.\nHis diarrhea persisted up to six liters daily despite empirical treatment with maximal doses of antidiarrheals, octreotide and cholestyramine. Repeat imaging, stool specimens, endoscopic evaluation and histopathology failed to reveal <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 29-year-old woman presented with superior visual field defect of 30 minutes’ duration in her left eye which had suddenly appeared after swimming.\nOn ocular examination, visual acuity was 20/20 and 20/32 in her right and left eyes, respectively. A weak relative afferent papillary defect was identified on the affected side. No remarkable finding was observed in the anterior segment of either eye. Funduscopic examination revealed a calcified white embolus at the first bifurcation of the inferior temporal artery of the left retina. Except for mild retinal edema in the left eye, no other ocular abnormality was noted.\nWith a diagnosis of BRAO, the patient was treated with oral acetazolamide, topical timolol, ocular massage, followed by anterior chamber paracentesis. Visual field loss partially recovered within 15 minutes after initiation of treatment, meanwhile the embolus moved to the third bifurcation level.\nVisual field testing (Humphrey Field Analyzer; Carl Zeiss, Jena, Germany) was performed two days after the onset of symptoms and disclosed a superior visual field defect in the left eye (). At the same t", "role": "user" }, { "content": " ime, fluorescein angiography depicted no embolus and delayed filling of the affected <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The patient is a 50-year-old African American female with a history of bilateral breast reduction twelve years ago, iron deficiency anemia, and obesity, who presented to the surgeon's office complaining of tenderness of her right breast. The patient reported that recently she had been developing keloids along the scar of the right breast with some areas having a blue hue; her left breast was unremarkable. She noticed that after wearing a sports bra there was increased pressure and abrasions to the keloid, leading to cellulitis and edema. She was previously treated with two courses of antibiotics for what was presumed to be an infected kelo", "role": "user" }, { "content": " idal scar of her right <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 52-year-old woman with a 3 month’s history of cough and hemoptysis consulted a nearby clinic. Chest X-ray showed atelectasis of the right upper lobe caused by locally advanced lung cancer with mediastinal in", "role": "user" }, { "content": " vasion. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 74-year-old female patient presented with the feeling of an abdominal growing mass and weight loss (approximatively 10 kg within the last 12 months) without rectal bleeding or abdominal pain. After a computed tomography (CT) scan the patient was referred to our hospital with the suspicion of a rectal tumor. Complex medical history included a subtotal colectomy with an end ileostomy and a mucous fistula at the descending colon due to Crohn disease at the age of 16 years. In the following years, the patient suffered from repeated ileus episodes and a laparotomy with adhesiolysis was performed in 2007. She never took any medication for her Crohn disease and no further manifestations of activity were observed. Clinical examination showed the patient in reduced general condition; the abdomen was soft and there was no pain during the palpation of the abdominal wall. Laboratory values were in the standard range.\nThe imaging in the CT scan was not", "role": "user" }, { "content": " conclusive, and therefore we performed <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 59-year-old woman was referred to our department for intraperitoneal chemotherapy for gastric cancer with peritoneal carcinomatosis. She had already received two courses of chemotherapy with S-1 plus cisplatin in the previous hospital. Upper intestinal endoscopy showed Borrmann type IV gastric cancer with ulceration at the upper part of the stomach (Fig. ). Pathological diagnosis was poorly differentiated tubular adenocarcinoma with the signet ring cell carcinoma. Staging laparoscopy showed a thickened omentum due to carcinomatosis (“omental cake”) and numerous disseminated nodules in the whole abdominal cavity. An intraperitoneal access port was implanted to allow for chemotherapy administration. After the staging laparoscopy, she received five courses of chemotherapy with intraperitoneal administration of PTX. At first, two courses with intraperitoneal administration of PTX, intravenous administration of oxaliplatin, and oral S-1 were done. Then three courses with intraperitoneal and intravenous administration of PTX and oral S-1 were done. Oxaliplatin was administered intravenously at a dose of 100 mg/m2 on day 1, and PTX was administered intravenously at a dose of 50 mg/m2 on day 1 and intraperitoneally via the access port at a dose of 20 mg/m2 on days 1 and 8, respectively. PTX was diluted in 1 l normal saline over 1 h. S-1 was administered orally twice daily at a dose of 80 mg/m2 per day for 14 consecutive days, followed by 7 days without treatment. These chemotherapy in clinical studies were approved by the institutional review board of The University of Tokyo. Repeat laparoscopy showed disappearance of the peritoneal carcinomatosis (Fig. –), after which she underwent total gastrectomy with lymphadenectomy. Pathological examination revealed no viable cancer cells remaining in the resected specimen (Fig. ). The patient received a total of 38 courses of chemotherapy with intraperitoneal and intravenous administration ", "role": "user" }, { "content": " of PTX and oral S-1 after the gastrectomy, without apparent metastasis or recurrence. Two years <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 25-year-old female presented to the emergency department (ED) for evaluation of persistent productive cough of yellowish sputum over the last four week and mild exertional dyspnea over the last two years. Her past medical history was unremarkable and she took no regular medications. There was no personal or family history of multiple endocrine neoplasia type 1 (MEN1) syndrome. She was in no distress on presentation to the ED with a resting hemoglobin oxygen saturation of 97% while breathing room air. Her physical examination was remarkable for absent breath sounds and decreased tactile fremitus on the left middle and lower lung fields. No wheezing or stridor were heard. Laboratory data were within normal limits.\nA chest x-ray (CXR) in the ED demonstrated opacification of the left middle and lower lung fields, hyperinflation of the right lung and deviation of the trachea to the left (Fig. ). A computerized tomography (CT) s", "role": "user" }, { "content": " can of the chest showed complete left lung atelectasis due to a mass <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 46-year-old woman of unknown ethnic origin presented to her primary doctor with a one-month history of a painless left breast lump without associated nipple discharge that was noticed by the doctor on examination. She was otherwise healthy with no other relevant history. Physical examination revealed a large, non-tender, freely movable mass in the left breast and multiple enlarged lymph nodes in the left axilla. Our patient reported no systemic B symptoms such as fever or weight loss. A biopsy of her left breast mass revealed a DLBC lymphoma. Our patient was then referred for staging with F-18 FDG PET/CT that was acquired from base of skull to upper thigh with the CT being low-dose and unenhanced. The PET/CT scan revealed a 8 × 10 cm hyperdense and intensely FDG-avid mass occupying almost the entire left breast with maximum standard uptake value (SUV) of 21 (Figure ). In addition, several left axillary lymph nodes measuring up to 5 cm in size and several left sub-centimeter internal mammary lymph nodes showed intense FDG avidity (Figure ), with SUV values of 33 and 3.3. However, PET/CT findings were suggestive a breast carcinoma rather than a lymphoma, based on the location and distribution of the lesion. Because of the rarity of breast lymphoma, it would be unusual to consider metastatic breast lymphoma in the differential diagnosis of breast tumors. As a result, it would have been impossible to distinguish breast lymphoma from breast carcinoma through PET/CT. An incidental finding of intense FDG uptake in the uterine cervix, SUV of 8, led to the subsequent pathologic diagnosis of a previously unsuspected squamous cell carcinoma (Figure ). The lesion appeared to in", "role": "user" }, { "content": " volve the proximal third of the vagina and the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 56-year-old man was referred to the gastrointestinal department with complaints of 2-weeks history of melena and epigastric dull pain. No mucous stool, no bowel habits change was present and he denied fever, nausea, or vomiting. Meanwhile, the patient's medical and family histories were normal. Physical examination revealed there was no anemia or enlarged lymph nodes such as Virchow lymph nodes. For laboratory tests, occult blood test of stool was positive. Hematological test revealed a normal level of hemoglobin (Hb), 130 g/L. Peripheral blood tumor markers were within the normal range too. Endoscopic examination showed erosive hemorrhage on the surface of the tumor with a diameter of about 7 cm (Fig. A). A biopsy of this area exhibited malignant tumor. Abdominal computed tomography (CT) showed a bulky mass with ulceration, located in the fundus of the stomach and marked thickening of the gastric wall (Fig. B). The tumor seemed to have invaded the pancreas and a few enlarged lymph nodes could be seen. Chest x-ray and other examinations showed no distant metastasis. Due to gastric bleeding along with the family members and patient's strong desire for surgery, the patient accepted surgery as the first treatment option. Total gastrectomy with D2 lymph node dissection was performed. It was found that", "role": "user" }, { "content": " the tumor was located on the lesser curvature of the stomach, and there was no other internal organ metastasis except for invasion of the upper edge of the pancreas which was resectable.\nGrossly, the tumor was hard in consistency with massive necrosis, ulcerated in the center and broke through serosa (Fig. ). Histologic evaluation revealed multiple different sections contained a proliferation of malignant epithelioid and spindle cells arranged in sheets and slit-like/vascular spaces (Fig. ). The lesion appeared to be centered in the deeper layers of the stomach (serosa and muscularis propria) with expansion up to the mucosa. Lesion cells, both in sheets and in slit-like vascular spaces showed <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 68-year-old, right-handed male presented with episodes of nausea and vomiting over the last year. These episodes could be precipitated by sudden head movement, physical exertion, or sometimes in response to changes in ambient temperature. The severity and frequency of the episodes gradually progressed. Mild gait instability was also noted. His only other medical history included hypothyroidism and dyslipidemia. There was no family history of cerebral aneurysms. There was no history of smoking or excess alcohol consumption. On examination, he had difficulty performing tandem gait but had no other neurologic deficits. No other cerebellar signs were noted.\nAn MRI of the brain, arranged by his family physician, demonstrated a partially thrombosed giant right PICA aneurysm filling the fourth ventricle (). The filling (non-thrombosed) component of the aneurysm measured 5 × 8 mm with a 2 mm neck. Mass effect was noted on bilateral dentate nuclei and cerebellar white matter as well as the pons. No AVM was detected on the MRI. There was no evidence of obstructive hydrocephalus. Conventional cerebral angiogram demonstrated that this aneurysm was arising from the right PICA on a segment distal to the caudal loop. It also showed a midline cerebellar AVM, with a nidus <3 cm, supplied by the right PICA. Another two smaller prenidal aneurysms were also noted more distally along the right PICA. In addition, the AVM is also supplied by the ipsilateral superior cerebellar artery (SCA) and drains superficially into the right transverse sinus through the torcula, Spetzler-Martin grade 1 (). The Right vertebral artery was dominant in this case, and each PICA arises from the V4 segment of the respective ipsilateral vertebral artery.\nAfter a detailed discussion with the patient and a review of both endovascular and open microsurgical options, the patient underwent endovascular treatment of the giant aneurysm with coil embolization/parent vessel occlusion (treatment decision and rationale are discussed be", "role": "user" }, { "content": " low). Though all approaches, including endovascular and microsurgical <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "Our patient, a 42-year-old, right hand dominated female was brought to the trauma center after a history of a fall from the first floor of a building. She presented with pain in the left arm and elbow. On examination, there was swelling and tenderness at the left mid-arm and left elbow and the neurovascular status was normal. Examination of the spine and lower limbs did not reveal any abnormality. A radiograph of the left upper extremity showed a transverse fracture of the mid-middle third-diaphyseal fracture of the humerus with a concomitant distal humerus fracture. A CT scan done for the elbow showed a comminuted fracture of the distal humerus (OTA/AO-13-C2) with a Type III capitellar fracture (Figure ). The arm was immobilized in a splint, and the patient was shifted to the ward.\nSurgical technique\nThe rotation of the right arm was checked and recorded. The patient was positioned in a right lateral decubitus position following the administration of general anesthesia. The operative arm was placed at 90 degrees of forward elevation and internal rotation over a padded post such that the forearm could be flexed beyond 100 degrees. A 5 cm posterior incision was marked, starting 5 cm distal to the posterolateral acromion in line with the triceps. While approaching the olecranon, another incision starting 5 cm proximal to the tip of the olecranon was marked, curving around the olecranon over the medial aspect and ended up 5 cm distal to the tip of the olecranon over the subcutaneous border of the ulna. The incision was made along the marked line, and a full-thickness fasciocutaneous flap was develope", "role": "user" }, { "content": " d (Figure ). Dissection was carried out between the middle and posterior <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 45-year-old woman with a history of open Fobi-Capella RYGBP was diagnosed with primary biliary cirrhosis and listed for LT. Bariatric surgery was carried out seven years before, followed by an emergency reintervention for obstruction of the jejunojejunostomy. Hepatopathy was diagnosed at 41 years of age. The patient presented Ig G antibodies for cytomegalovirus and a negative viral DNA detection by quantitative PCR. There were no other relevant comorbidities.\nShe was admitte", "role": "user" }, { "content": " d to the emergency department with melena and hematochezia. Physical <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 50-year-old African American male with a history of hyperthyroidism, hypertension, and congestive heart failure presented to an outside hospital with fever and an altered mental status. He was diagnosed with hyperthyroidism about three months prior to hospitalization. He was started on methimazole (MMI), but compliance taking the medication was low. His primary care provider had recommended thyroidectomy; however, he was unable to have the procedure due to la", "role": "user" }, { "content": " ck of health insurance. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 69-year-old Caucasian man presented with intermittent upper abdominal pain, nausea and bloating for the previous 12 months. There was no history of fever, jaundice, pale stools or dark urine. His past medical history included a Billroth II gastrectomy and Roux-en-Y reconstruction for peptic ulcer disease 11 years earlier. On examination, he was haemodynamically stable and afebrile. Abdominal examination was unremarkable. Lab", "role": "user" }, { "content": " oratory tests, including liver function tests and inflammatory markers were all normal. Transabdominal ultrasound examination revealed gallstones and intra- and <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 47-year-old woman presented at our emergency room with anterior right knee pain, one day after a fall at home on level surface. She was unable to stand on her right leg. No previous trauma or knee pain was reported. Past medical history was positive for pituitary dwarfism and epilepsy. Physical examination revealed knee effusion and anterior hematoma. The knee was stable in all directions. Passive range of motion was complete, but the patient was unable to actively extend her knee. A complete extension lag was observed.\nKnee radiographs were obtained and demonstrated a significant diastasis between two patellar parts (Figures and ). As both parts presented regular contours without evidence of acute fracture rims, further investigation was required. Magnetic resonance imaging (MRI) confirmed the presence of an intermediate ruptured tendon between the two patellar parts ().\nThe diagnosis of an intermediate tendon rupture in a duplicate patella was stated. In order to restore the integrity and length of the extensor mechanism, we proposed an anatomical repair of the intermediate tendon. The surgery was performed the same day.\nSurgery was performed under general anesthesia, standard intravenous antibiotic prophylaxis, and tourniquet. A longitudinal 10 cm incision was centered on the patellar parts. Immediately after skin opening a voluminous hematoma was discharged at the level between the two patellar parts. A ruptured tendon was observed at this level. The two patellar parts were identified, without evidence of an acute or old fracture. A strip of tendon with the characteristics of a fully developed insertion was observed at both the distal part of the proximal patellar piece and the proximal aspect of the distal patellar part (). The medial and l", "role": "user" }, { "content": " ateral retinacula were ruptured. The knee was positioned <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "We present a case of a 67-year-old female who was recently treated with a decompression and 10th thoracic to second lumbar fusion secondary to formation of an epidural hematoma from a 12th thoracic vertebra fracture (type unknown). While in a physical therapy session the patient suffered a fall forward, trying to break her fall with her arms outstretched above her head. After the fall the patient’s arms were stuck in full abduction and pronation and she was in significant pain. The patient’s presenting position is displayed in . She arrived in the emergency department where X-rays were taken and demonstrated bilateral inferior shoulder dislocations, LEH ().\nOrthopedics was consulted to evaluate and treat. Upon evaluation, the patient was distally neurovascularly intact with 2/4 radial pulses bilaterally, sensation intact to light touch about the fifth cervical to first thoracic dermatomes,", "role": "user" }, { "content": " and motor function was intact in all peripheral motor groups of the upper extremities. The emergency physician provided sedation with closed reduction performed by the orthopedic service. The right shoulder was reduced using traction through the humerus through a flexed elbow to control the limb, and the opposite hand was used to place superior pressure on the humeral head through the axilla to guide the head into the glenoid. Slight external rotation and adduction was added as the head cleared the glenoid. Attention was then turned to the left shoulder, which was reduced, in a similar fashion; however, this shoulder was converted from an inferior to anterior dislocation using pressure in the axilla and slight external rotation.\nFollowing this, traction through the humerus external rotation, and lateral pressure on the humeral head yielded a successful relocation of the glenohumeral joint. After reduction the patient remained neurovascularly intact bilaterally. The patient was placed into bilateral shoulder slings, advised to avoid active shoulder range of motion, and admitted to the hospital for placement. Three days after the patient’s admission she adjusted a continuous positive airway pressure (CPAP) mask <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 66-year-old man presented complaining of a dull chest pain and dysphagia. He had been diagnosed with a type II chronic dissecting thoracoabdominal aortic aneurysm. Seven years prior, the patient underwent a hemiarch descending aortic replacement with a right subclavian artery bypass due to a ruptured acute type B aortic dissection with anomalous origin of the right subclavian artery from the descending aorta. After the operation, the patient was followed regularly at the outpatient clinic and developed a distal aortic aneurysm from the end of the arch graft to both iliac arteries with a maximal diameter of 6.5 cm at the diaphragm level, which caused the symptom of dysphagia (). We planned to perform a staged debranching endovascular stent-graft repair of the total remaining aorta including both common iliac arteries.\nThe first operation was the visceral debranching procedure. Through a midline abdominal incision, the abdominal aorta and its main branches were dissected and exposed, including both iliac arteries, both renal arteries, the superior mesenteric artery, and the celiac trunk. They were replaced with a custom-designed graft made of a 14×7 mm and a 16×8 mm Dacron Y graft (Intervascular, La Ciotat, France) (). The proximal abdominal aortic anastomosis was made at the true lumen of the infrarenal abdominal aorta after obliterating the pseudolumen, and the other branches were anastomosed end-to-end separately. The total operation time was seven hours and fifteen minutes, and the patient remained in the intensive care unit for four days. The total transfusion required was 17 units of packed cells, 11 units of fresh frozen plasma, and 2", "role": "user" }, { "content": " 0 units of platelets. Two weeks after the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 42-year-old male was referred for left wrist drop, finger drop and a tingling sensation over the lateral dorsum of the left hand. The patient reported that he was well until 4 days prior when he was intoxicated and awoke with the symptoms. For 4 days, slight improvement of weakness occurred. He had no ", "role": "user" }, { "content": " history of antecedent trauma, injury, infection, or mononeuropathy. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "In 2015, a 24-year-old male was referred to our hospital for evaluation of gingival swelling in the mandibular left posterior region. The patient was a non-smoker and had no underlying disease. He had first noticed the lesion about one year prior. On extra-oral examination, facial asymmetry with swelling involving the left side of the mandible was observed at the time of admission. Intraoral examination showed a discharge of pus in the posterior region.\nX-ray radiographs (panoramic radiograph and computed tomography [CT]) were performed.() Axial CT showed a fairly large (27 mm×34 mm×23 mm) and well-defined rounded cystic destructive lesion involving the left mandibular body. Absorption of the roots of #36 and #37 had occurred. Incisional biopsy was performed under local anesthesia, and the tissue was sent for histopathological examination, which revealed a suggestive benign cyst. Endodontic treatment of #36 was performed.\nAt the time of operation, extraction of #37 and #38 and enucleation of the lesion were carried out under general anesthesia. The iliac bone graft took place at the same time. After surgery, a newly exc", "role": "user" }, { "content": " isional biopsy was performed, and the results did not show a benign cyst but instead were suggestive of unicystic ameloblastoma, mural type.() A follow-up check was done at three months, six months, nine months, and one year after surgery. Nine months postoperatively, a panoramic radiograph revealed favorable healing of the iliac bone graft in the left mandibular body.()\nAt one year and five months after surgery, implantation of #37 was performed. The implantation was done using a one-stage technique because the initial torque was favorable. () Based on the results of the initial histopathological examination, cyst enucleation and an iliac bone graft were performed simultaneously in this patient. Usually in cases of ameloblastoma, a bone graft is not carried out at the same time due to the high recurrence rate. In this case <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 67-year-old woman with remote history of endocarditis s/p tricuspid valve repair and mechanical aortic valve replacement was referred for second opinion and management of new severe symptomatic tricuspid valve stenosis resulting in progressive debilitating congestive heart failure (HF). The patient was approved by the heart team to undergo redo open heart for surgical repair of the tricuspid valve. Intraoperative technical challenges were met to repair the tricuspid valve. In turn, the native valve was resected and a 33 mm On-X mechanical valve prosthesis (On-X Life Technologies, Austin, TX, USA) was implanted.\nThe patient’s post-operative course was complicated by recurrent haemoptysis related to endotracheal tube trauma, prolonged mechanical respiratory support, acute kidney injury, and cardiogenic shock. While unable to anticoagulate, increasing requirements of inotropic and vasopressor support were noted. On the fifth post-operative day, 2D examination revealed single leaflet fixation of the tricuspid mechanical prosthesis resulting in severe stenosis, along with moderate size iatrogenic ventricular septal defect (VSD) not previously seen and later confirmed on transesophageal echocardiography (TEE) (Figure ). The mechanism for the leaflet dysfunction remained unclear. There appeared to be no evidence of leaflet thrombosis. The left ventricle and mechanical aortic valve function remained preserved. Using a heart team approach, it was felt that surgical re-exploration to address the dysfunctional mechanical tricuspid valve and VSD would be prohibitive. A transcatheter assessment with ad hoc intervention was considered. Upon obtaining consent from the patient’s next of kin, the patient was emergently taken to the cath lab for further evaluation and management.\nThe patient was transferred to the cardiac catheterization laboratory in severe haemodynamic collapse. Initial fluoroscopic examination of the heart confirmed the echocardiographic results of an immobile", "role": "user" }, { "content": " septal leaflet of the recently implanted mechanical tricuspid valve (Figure ). A 9 Fr St. Jude Viewmate intracardiac echo-catheter was used to further assess the TV function and assist with trans <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 36-year-old male presented with right anterior ankle pain which had been intermittently occurring for several years following a right ankle fracture. Physical examination revealed a pes planus deformity of the right ankle with tenderness over the anterolateral joint line, the peroneals, and the anterior talofibular ligament. Ankle movements were limited to 2° of dorsiflexion and 20° of plantarflexion. Radiographs of the right ankle demonstrated osteophyte formation in the anterior ankle with medial talar dome sclerosis, suggestive of a medial talar dome osteochondral defect [, ]. A CT scan of the right ankle showed a large medial talar dome osteochondral defect, multiple loose bodies, and osteophytes [–]\nThe patient failed conservative therapy with a lace-up ankle brace and 2 months later underwent an arthroscopic right ankle synovectomy and a medial osteochondral defect microfracture through standard anteromedial and anterolateral portals. The lateral incision was extended to resect the anterior tibial osteophyte due to its large size. Ten days following his surgery, the sutures were removed and an elasticized cloth bandage was placed at the level of the ankle joint to hold dry dressings in place. The patient was instructed to remove the dressing after 24 h. The patient remained non-weight-bearing for the first 6 weeks following his ankle arthroscopy.\nAt his sixth week visit, the patient still had the previously placed elasticized cloth b", "role": "user" }, { "content": " andage and dressing in place. The patient had not removed <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 52-year-old woman with rheumatic heart disease and atrial fibrillation was scheduled to undergo a mitral valve replacement and Maze operation for severe mitral stenosis. She had a history of decompressive craniectomy due to cerebral swelling and right middle cerebral artery infarction 1 year prior, and sequela included persistent weakness of her left side. Preoperative transthoracic echocardiography revealed normal left ventricular systolic function (ejection fraction, 63%) and no regional wall motion abnormalities. Anesthesia induction and maintenance were performed as usual, and routine cardiac anesthesia monitoring was conducted. The mitral valve", "role": "user" }, { "content": " replacement was a 27-mm St. Jude Medical valve prosthesis (St. Jude Medical, Saint Paul, MN, USA), and the Maze operation proceeded well under cardiopulmonary bypass (CPB). Myocardial protection was performed via an infusion of cold cardioplegia via the aortic root cannula. Intraoperative transesophageal echocardiography showed no paravalvular leakage. Immediately after an aortic cross clamp, the cardiac activity was converted to normal sinus rhythm but returned to atrial fibrillation after a few minutes. Left ventricular systolic function remained normal. The patient was weaned from the CPB. After the operation, the patient was transferred to the ICU. The patient’s vital signs were controlled through administration of dobutamine and norepinephrine, and tachycardia was controlled through amiodarone. The patient’s blood pressure was maintained at 110/60 mmHg, and her oxygen saturation was greater than 97%. Extubation was performed the day after the operation. However, at 2 days postoperatively, the patient complained of dyspnea and chest discomfort, and electrocardiogram (ECG) revealed a premature ventricular complex. Transthoracic echocardiography revealed decreased left ventricular ejection fraction to 26% and akinesia of the middle and apical wall of the left ventricle (). Takotsubo cardiomyopathy was suspected, but coronary artery disease could not be completely ruled out. On the 4th postoperative day, the patient developed pulmonary edema and hypoxemia. The patient’s systolic blood pressure was 80 mmHg, and heart rate was 150 beats/min. The <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 43 years old female patient was previously submitted to laparoscopic gastric bypass for morbid obesity without co-morbidities. Seven months after the bariatric surgery the patient showed intense episodic epigastric abdominal pain that was aggravated by food ingestion and led to multiple visits to the emergency room.\nOne month after the onset of pain complaints, the patient was offered hospital admission for further evaluation. Physical examination was unremarkable and routine blood assessment of liver and pancreatic functions were normal. The upper endoscopy and esophageal-gastro-jejunal transit were normal; the abdominal CT and MRI were considered normal despite the presence of a mass in the excluded stomach, as it was ascribed to the anatomical rearrangement after the bypass surgery (Figure A). During hospital stay the patient did present any evidence of abdominal pain, complaints or need for analgesia; after formal psychiatric evaluation, a major depression was diagnosed and the patient was started on anti-depressants.\nFive years after gastric bypass, due to ongoing epigastric pain complaints, abdominal CT and MRI were repeated, with subsequent diagnosis of a 4.5 cm of greater diameter subserosal neoplasm in the antrum (Figure B).\nThe patient underwent laparoscopic gastrectomy of the excluded stomach for suspected gastrointestinal stromal tumor (GIST) (Figure A). Gross examination of the specimen revealed a subserosal polypoid mass in the gastric antrum, which corresponded to a 4.5 cm cystic cavity of greater diameter with creamy yellowish thi", "role": "user" }, { "content": " ck content, growing in dependency of the gastric muscular layer (Figure B). The histology of the mass showed <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 24-year-old female patient with a history of primary repair for ASD performed 8 years ago admitted to our clinic for her annual checkups. In her previous primary repair surgery, the defect was closed directly with an atriotomy incision followed by 5/0 polypropylene and 4/0 polypropylene sutures. The patient had attended her ensuing controls every three months for a period of one year, and no pathological findings were identified during this peri", "role": "user" }, { "content": " od. There was no history of any drugs being used recently. Physical examination was normal, and routine hematological and biochemical laboratory analysis were within normal levels. Electrocardiogram revealed normal sinus rhythm and right bundle branch block. Transthoracic echocardiography (TTE) revealed normal left ventricular systolic functions, mildly dilated right chambers, minimal mitral regurgitation, mild tricuspid regurgitation, systolic pulmonary artery pressure of 30 mm Hg, and an irregular-shaped mass in the right atrium. On her transesophageal echocardiography (TEE) examination, a 3.7×3.5 cm sized giant pedunculated mobile mass was observed being attached to the septum in the right atrium (). After the procedure, the patient was hospitalized. Chest computed tomography (CT) showed no evidence of pulmonary embolism, and ventilation/perfusion scans indicated no problems. Protein C, protein S, and antithrombin III levels were within the normal range. Venous bilateral Doppler of lower extremity and abdominal ultrasonography results were normal. The patient was scheduled for excision of the mass. Surgery was performed via a median sternotomy by utilizing the cardiopulmonary bypass. Venous drainage was via the superior vena cava and the right femoral vein. The right atrium was being opened, and a large mass filling the entire atrium and obstructing the tricuspid valve was observed. The mass was intimately attached to the free atrial wall, it was irregularly-shaped, and 2.2×4.1 cm in dimension. It had a tanned, gelatinous appearance, and showed multifocal areas of calcification. The entire free wall of the right atrium mass was resected. The patient was weaned <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 24-year-old gentleman with no past medical history had been experiencing debilitating chest pains for 2 years. He described these as varying in intensity, worsened by exercise, and relieved partially by analgesia. They were not associated with palpitations or syncope.\nUnfortunately, due to his symptoms he had to give up his studies and minimize his physical activity. He had trialled multiple analgesics (daily paracetamol and tramadol) with partial relief of symptoms.\nHe underwent serial investigations at his local cardiology unit, including a cardiac CT which identified an absence of pericardium on the left side of the heart. He was referred to the Adult Congenital Heart Disease (ACHD) team at The Royal Brompton Hospital.\nWhen first reviewed in the ACHD clinic he was not cyanosed, in sinus rhythm with no evidence of cardiovascular decompensation. His apex beat however was grossly displaced to the left and more so on lying supine. His first heart sound was normal, second split, there was also a soft one-sixth systolic heart murmur. The rest of his examination was unremarkable.\nHis electrocardiogram showed him to be in sinus rhythm at 78 b.p.m., with normal conduction times but a poor R wave progression and an intermittently changing axis.\nA chest radiography (Figure ) which showed situs solitus, levocardia, with a left aortic arch, no displacement of the heart to the left, and a protrusion at the level of the left atrial appendage at the left upper quadrant of the heart.\nHis echocardiogram showed a stru", "role": "user" }, { "content": " cturally normal heart with maintained ventricular function. Stress echocardiography showed mild right ventricular dilatation at <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 63-year-old woman was admitted to our hospital in December 2017 with a mass in the urethral orifi", "role": "user" }, { "content": " ce. She had noticed the mass 2 yr prior without any diagnosis and treatment, and it had slowly increased <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 10-year-old girl presented to the ophthalmic department with right eye drooping and double vision for 1 day. She had headache for 1 week. She had a history of suffering headaches about four to five times a year since age 2 years; her headaches caused a dull pain sometimes accompanied by nausea and vomiting. Because of the recurring headaches, she had undergone MRI of the brain in the pediatric department 1 year ago, which had revealed no evidence of abnormality. Her mother reported that this was not the first time she was experiencing ocular movement limitation during headache. A similar ocular motility disorder had developed when she was 2 years old and lived in the United States at that time. She had been diagnosed with a typical cranial neuropathy in the right eye, which had improved after administration of a steroid. The visual acuity was 20/20 in both eyes. The right pupil was poorly reactive to direct and consensual stimulus. The ocular motility examination showed a limitation of ocular movement except abduction in the right eye []. There was no ocular injection, chemosis, or pain on eye movement. The f", "role": "user" }, { "content": " undus showed normal appearance of <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 39-year-old male patient reported to the dental institute with the complaint of pus discharge from right lower posterior region of the jaw since one month ago. The patient noticed decayed teeth in the same region, which was not associated with pain. He had visited a private dental clinic, where decayed tooth had been extracted and medications had been given for about 5 days.\nOn general physical examination, the patien", "role": "user" }, { "content": " t was well built, 182 cm tall with normal gait and satisfactory vital signs. The extraoral examination revealed hypertelorism, strabismus, and a cystic swelling on the left eyelid as well as his neck (). Intraoral examination revealed missing teeth of the right mandibular first and second molars and pus discharge from the same region. No other skeletal abnormalities were detected.\nPanoramic radiograph revealed well defined multiple unilocular radiolucencies with sclerotic borders in the mandibular body, ramus, and symphysis areas. The unilocular radiolucencies varied in diameter from minimum 3 cm to around 7 cm in diameter. The largest one was located in the body of the mandible on the right side extending superiorly from the edentulous area to the lower border of the mandible inferiorly. Three smaller radiolucencies measuring around 3 cm in size were located in the posterior part of the right mandibular body and ramus as well in the left symphysis region. A smaller radiolucency measuring around 1 cm in size was observed in the periapical region of the right maxillary third molar. There was no radiographic evidence of tooth displacement and root resorption (). Cross sectional mandibular occlusal radiograph revealed a radiolucent area with minimum cortical plate expansion (). The findings of panoramic radiograph raised the possibility of Gorlin-Goltz syndrome and further investigations were carried out. Chest radiograph revealed the bifid fourth and eighth rib on the right side ().\nCT images showed hypodense areas in relation to the right mandibular body separated by a hyperdense septae <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 24-year-old woman from a Middle Eastern country presented to the Jefferson Pancreas, Biliary and Related Cancer Center for evaluation of a recurrent pancreatic mass. She complained of right upper quadrant fullness, and physical examination revealed a remote right subcostal incision. At the age of 12 years, she had first developed decreased appetite, weight loss, fatigue, pruritus, and subsequently became jaundiced. Medical records from that episode revealed that an endoscopic biliary stent was placed with surgical exploration through a right subcostal incision and partial resection/enucleation of a pancreatic mass. In the intervening 12 years, the mass had persisted and enlarged, although the patient was asymptomatic, having neither anorexia, pruritus, nor jaundice.\nRoutine hematology and basic chemistry panels were normal. The tumor marker cancer antigen 19-9 was mildly elevated at 89 U/mL (<35 U/mL). An abdominal computed tomography (CT) scan with contrast revealed an 8.2 × 7.6 cm heterogeneous-enhancing lesion, prominently involving the uncinate process of the pancreas (). The pancreatic head and neck were displaced and splayed around the anterior aspect of the tumor. The mass abutted the superior mesenteric vein (SMV) as we", "role": "user" }, { "content": " ll as the superior mesenteric artery <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 29-year-old female patient with end stage renal failure was our recipient. She was considered for a pre-emptive transplant and the only viable living donor was her 59-year-old mother. Upon evaluation for the donor, all the criteria were met except for the detected horseshoe kidney by CT scan. Dynamic CT revealed one renal artery and one renal vein for each side, a long but thin isthmus connecting lower poles with no visible arterial supply (). Sizes of the left and right kidneys were 110 × 38 cm and 117 × 42 cm, respectively. Absence of a connecting caliceal system was established with a descending urography. We did not perform a dynamic renal perfusion scintigraphy to assess the split functions of the kidneys since their sizes, respective vasculature and measured GFR values indicated sufficient capacity for each kidney. Left portion of the kidney was considered for nephrectomy.\nWith a left subcostal incision transperitoneal exploration was performed. The left kidney had indeed one renal artery and one renal vein. There were two ureters for the left kidney. The vessels, ureters were prepared and the kidney was mobilized up to the isthmus. A temporary bulldog clamp was put on left renal artery to deter", "role": "user" }, { "content": " mine the demarcation zone and it was shown to form around isthmus (). The artery and vein were divided and <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "Recurrent urinary tract infections most recently on 2 23 97 recurrent aspiration pneumonias most recently on 2 21 97 multi-infarct dementia with associated dysphasia mitral regurgitation history of congestive heart failure pernicious anem", "role": "user" }, { "content": " ia chronic venous <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 75-year-old woman (virgo, gravida 0, para 0, body mass index (BMI) = 21) presented with diffuse abdominal pain and enterorrhagia. She entered menopause at the age of 55 and she had regular menstrual cycles with no dysmenorrhea. Her medical history includes hypertension treatment with angiotensin II receptor blocker. She had undergone knee arthroplasty bilaterally and had never complained of bowel or reproductive system symptoms before, while there is no family history of colorectal or endometrial neoplasms.\nThe patient underwent colonoscopy, which was not completed due to bowel intussusception, 28 cm from the anus. It was assumed that intussusception was the result of external pressure. Blind biopsies were performed and the relevant histopathological examination revealed intestinal mucosa with tubular adenoma of low-grade dysplasia. Computed tomography (CT) of the upper and lower abdomen demonstrated a midline pelvic lesion with a transverse diameter of 6.1 cm ( and ). Additionally, two more nodal lesions with a transverse diameter of 2.8 cm each were found in a cephalad and caudal direction (). The caudal lesion was found to be in contac", "role": "user" }, { "content": " t with the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 20-year-old woman was admitted to the ophthalmology department with progressive bilateral upper eyelid swelling for 6 months. She had no other symptoms related to her eyes. A physical examination revealed dry mouth and nasal congestion. She had a history of triamcinolone (Nasacort) nasal spray usage for nasal congestion for nine months. Her family history was unremarkable. Her best corrected visual acuity was 10/10 in both eyes. The only pathologic finding identified through slit-lamp biomicroscopy was the presence of bilateral, symmetrical, solid, lobular masses in the lateral upper eyelids at the location of the lacrimal glands (). There was no proptosis. The patient’s dilated fundus examination was unremarkable. Intraocular pressure was measured as 16 mmHg in both eyes. Pupillary response to light and eye movements was normal. The result of a Schirmer test without anaesthesia was 1 mm/5 minutes in both eyes.\nSkin examination revealed subcutaneous nodules in the scalp. Upon systemic examination, the bilateral parotid and submandibular glands appeared swollen (). Magnetic resonance imaging (MRI) of the orbit rev", "role": "user" }, { "content": " ealed involvement of the superior eyelids and the anterior orbit and bilateral symmetrical diffuse enlargement of the lacrimal glands with an isointense signal intensity relative to muscle on T1-weighted images and a hypointense signal intensity on T2-weighted images (). On MRI, the maximum and minimum thicknesses of the lacrimal glands were 11 mm and 7 mm, respectively. Parotid and submandibular glands were evaluated with ultrasound and MRI. Neck ultrasonography showed heterogeneous and hypoechoic areas in the parotid and submandibular glands bilaterally. MRI of the neck showed bilateral cervical lymph nodes of pathological size and bilateral enlargement of the parotid and submandibular glands with a heterogeneous appearance. For definitive diagnosis, a lacrimal gland biopsy was taken from the orbital lobe using an upper lid crease incision. Microscopic examination showed discrete non-necrotising granulomas (). Acid fast bacilli were not identified by Ehrlich-Zie <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "RTA d", "role": "user" }, { "content": " iagnosed at 14 months of age she had a history of scarlet fever at 14 months of age She also had a recent exposure to varicella . Her brother had developed the typical rash on 9 3 93 <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 51-year-old man with 50 years history of hemophilia A presented to our institution with aggravated abdominal and left hip pain. The pain in his abdomen could reach 6 points using visual analogue scale and could not be alleviated with rest. Physical examination revealed the giant mass around his left hip with tenderness. Ultrasonography demonstrated a giant retroperitoneal mass sized 10 cm × 6 cm, and part of the tumor herniated from the left abdominal wall and located under the subcutaneous adipose layer. His medical treatment includes recombinant factor VIII concentrate 800 IU almost once a week for the past 6 years and painkillers. A computed tomographic scan and magnetic resonance imaging demonstrated the giant retroperitoneal hemophilic pseudotumor (Fig. A–E). Abdomino-pelvic imaging showed further irregularities including compression of adjacent organs and significant bone destruction of left ilium. No relevant special circumstances regarding his family history or personal history were identified. The neurological examination result was essentially normal. Based on these findings, the giant retroperitoneal hemophilic pseudotumor was considered.\nAfter detailed analysis, the patient underwent surgical excision of the giant hemophilic pseudotumor and the patient was given an infusion of factor VIII in order to maintain factor VIII activity between 40% and 50% in the immediate postoperative period. Histopathologic examination including immunohistochemical staining was performed, and the diagnosis of hemophilic pseudotumor was made according to the criteria. The postoperative pathology together with symptoms and", "role": "user" }, { "content": " examinations was reported to be consistent with the giant retroperitoneal hemophilic pseudotumor.\nOne week after the operation, the visual analogue scale score of his abdominal pain improved to 0–1 points compared to the preoperative status, 6 points. The coagulation factor index remained within the ideal range. Subsequently, we administered combination medical treatment, the symptoms were successfully relieved gradually. At the 5-year follow-up visit, he had nearly full complete remission and reported palliative pain. There was no complication during the postoperative period. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 48-year-old otherwise healthy woman had suffered epigastric and back pain for 4 weeks. At first, gastroscopy was performed showing no pathological findings. Subsequent contrast-enhanced computed tomography depicted a 3.3 cm lesion in the body of the pancreas with invasion of the celiac axis (). Therefore, the tumor was declared unresectable in an external hospital, and a palliative chemotherapy with gemcitabine and erlotinib was initiated. After 3 cycles of chemotherapy, she presented to our clinic to be reassessed. We carefully reviewed the findings and agreed a surgical approach with her. The patient underwent laparoscopy to exclude hepatic and peritoneal metastasis. Subsequently a selective embolization of the common hepatic was performed. First celiac and superior mesenteric artery angiograms were obtained to confirm the presence of the pancreatoduodenal arcade. Thereafter, a 6F sheath was placed in the common hepatic artery. After the identification of the origin of the gastroduodenal artery an 8 mm Amplatzer vascular plug 4 (AGA Medical Corp., Plymouth, MN USA) was placed in the common hepatic artery (). Completion ", "role": "user" }, { "content": " angiograms <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 55-year-old female patient reported to the clinic with the complain", "role": "user" }, { "content": " t of a loose mandibular denture. The patient was unable to chew <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 63-year-old male patient with large anterior mediastinal mass was referred to our hospital for treatment. The patient was pathologically diagnosed as cervical schwannoma and underwent surgical resection twelve years ago. He had re-operation because of the recurrent neck tumor four years ago. No specific neural, cardiovascular and respiratory disfunction and neoplasms his history contained as well as his family history. The patient suffered from chest oppression and shortness of breath for four months, and these symptoms gradually became worse. The Preoperative CT confirmed that the patient was diagnosed as ", "role": "user" }, { "content": " TM and large anterior mediastinal mass (Fig. ) Due to occasion of severe airway overreaction during <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 12-year-old Vietnamese boy presented to our emergency department with bilateral knee pain and swelling. The mechanism of injury was sustained as a result of tripping with bilateral knee strikes on the ground while playing sports at school. The subject and his parents denied jumping in relation to the injury or any knee pain prior to the injury. The history revealed immediate pain and the inability to mobilise or bear weight.\nOn physical examination, the boy had an athletic constitution. There was significant appreciable bilateral knee swelling with a fixed flexion deformity on observation with pain being the limiting factor disabling knee extension. Generalised tenderness and an intra-articular effusion were present on palpation with the predominant source of pain at the tibial tuberosities. Any attempt of motion provoked severe pain. Given the pain, it was difficult to assess the integrity of the cruciate and collateral ligaments; however the limited examination did not reveal obvious instability. Neurovascular examination was normal and compartments were soft.\nInterestingly, the boy's past history was significant for a type IIIA left knee avulsion fracture that he sustained 13 months priorly. This happened via a different mechanism (jumping) where pain was felt while pushing off. On that occasion an MRI showed an injury to both ends of the patella ligament with some avulsion of the patella proximally and some lifting up of the tibial tuberosity distally. He was managed conservatively on that occasion in a hinged-knee brace locked in extension for six weeks with physiotherapy to progress ROM thereafter. The paediatric orthopaedic surgeon who reviewed him in the outpatient clinic made a specific note in his letter stating that “this injury will have changed the relative length of his patella by a small amount”, going on to say that “we will need to take this slowly in terms of pro", "role": "user" }, { "content": " tecting this.”\nOn this presentation, plain radiographs (Figures and ) showed bilateral tibial tuberosity avulsion fractures. The previously <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 61-year-old female patient without any medic", "role": "user" }, { "content": " al history presented at our clinic with a <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 8-month-old Caucasian baby boy with heterotaxy syndrome was admitted to our general pediatric ward after presenting to a scheduled clinic visit with fever, hypoxemia and cyanosis. His history was significant for dextrocardia, polysplenia, interrupted inferior vena cava, biliary atresia status post-Kasai procedure, and malrotation status post-Ladd’s procedure. He was febrile on presentation, and was started on oxygen via nasal cannula for oxyhemoglobin saturations as low as 70%. His chest radiograph on admission showed a patchy right lower lobe opacity, and he was started on antibiotics out of concern for pneumonia. He was subsequently transferred to our pediatric intensive care unit (PICU) for refractory hypoxemia requiring high flow oxygen therapy.\nThroughout his PICU admission, he continued to require high flow oxygen up to 9L per minute and fraction of inspired oxygen (FiO2) of 1 to maintain oxyhemoglobin saturation greater than 75%, with persistent desaturations while upset. Early in his admission, he developed increased work of breathing requiring positive pressure ventilation with bilevel positive airway pressure. A ches", "role": "user" }, { "content": " t radiograph revealed pulmonary edema, and brain natriuretic peptide (BNP) at that time was elevated at 1130pg/mL. His pulmonary <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 73-year-old male, diabetic for 11 years, hypertensive for the past", "role": "user" }, { "content": " five years and with ischemic heart disease presented with gradually progressive painless loss of vision in the right eye of three weeks duration. He had an indwelling double lumen subclavian catheter and was undergoing dialysis once every three days for chronic renal failure. The patient was on oral prednisolone 10 mg daily for systemic myasthenia gravis since 1981. He had undergone cataract extraction with intraocular lens (IOL) implantation in the right eye three years ago.\nHis visual acuity was 20/100, N36 and 20/20, N6 in the right and left eye respectively. The anterior segment evaluation of the right eye showed 2+ cells and a sluggish pupil. The right eye was pseudophakic with a clear posterior capsule. The fundus evaluation showed multiple cotton-ball opacities in the vitreous and few had coalesced to a ‘string of beads” appearance []. An area of active chorioretinitis and arteritis along the superotemporal arcade was noted. Slit-lamp biomicroscopy showed numerous vitreous cells. The clinical picture was typical of endogenous endophthalmitis in the right eye most probably due to Candida species.[] Fundus evaluation of the left eye showed an old branch retinal vein occlusion with photocoagulation scars and changes suggestive of mild non-proliferative diabetic retinopathy.\nPars plana vitrectomy and intravitreal amphotericin-B was planned at first visit itself. But as he was due for dialysis the same day, after discussing with the nephrologists, taking into account the multiple co-morbid conditions of the patient he was started on voriconazole. Oral voriconazole 200 mg twice daily was started along with prednisolone acetate eye drops every 2 h and atropine sulphate 1% eye drops thrice daily. When he came for follow-up two days after dialysis, his general condition as well as the ocular status was much better. The cellular reaction had reduced with 1+ cells and the media clarity was marginally better. Therefore, we thought it <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 60-year-old African American female was following up for her chronically elevated alkaline phosphatase levels. She had a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, allergic rhinitis, and chronic lower back pain. Patient has a family history of arthritis, cardiovascular disease, and diabetes mellitus; she denies ever using alcohol or tobacco.\nWith the onset of elevated alkaline phosphatase level and vague abdominal pain in 2013, an abdominal ultrasound performed in December showed hepatic steatosis. Viral serologies for hepatitis during 2013 were negative, as a gastrointestinal consult was required to determine the need for a liver biopsy. A liver biopsy was subsequently performed, which showed focal mixed micro and macrovesicular steatosis. Portal tracts showed minimal focal chronic inflammation, no significant fibrosis, and no iron deposition.\nThe vague abdominal pain that she was experiencing waxed and waned for two years. Additionally, the patient experienced some vague chest pain and dyspnea that prompted an echocardiogram in February of 2015, which demonstrated a left ventricle ejection fraction of 44%. Consequently, a left heart catheterization in the following month showed no significant coronary disease with a dilated left ventricle with an ejection fraction of 50%. A 2-year follow-up in July of 2015 showed suspicious cirrhosis by Computed Tomography (CT) scan (), possibly due to granulomatous changes and chronic inflammation. A CT scan was determined to be necessary for our patient because of rising alkaline phosphatase without other explainable etiologies, in addition to the patient's appetite suppression and vague abdominal pains. Patient's weight during this time was 207 lbs (93.89 kg) and was advised to diet and exercise. After 4 mo", "role": "user" }, { "content": " nths of continuous symptoms, especially with abdominal pain, a laparoscopic cholecystectomy was performed <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 56-year-old male with a history of hypothyroidism and hyperlipidemia was admitted to the hospital after a motor vehicle acc", "role": "user" }, { "content": " ident where he sustained a closed <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 39-year-old woman was referred to the Department of Otolaryngology—Head & Neck Surgery for a 2-month history of mild left-sided maxillary discomfort, severe left nasal obstruction, and smelly discharge. The history of the patient was characterized by tooth loss in the second quadrant (25 and 26). Patient benefited from the placement of dental implants 3 months before the consultation. First, the surgeon proceeded to the placement of a bone graft for a sinus lift, and, a couple of days later, the placement of three dental implants in the new grafted bone. At this time, the implants were correctly placed regarding the surgeon. According to the anamnesis, the patient benefited from the surgery in an emerging country (medical tourism). The postoperative imaging showed the correct position of the dental implants. One month after the surgical procedures, the patient developed the first rhinosinusal symptoms. The maxillofacial examination showed a giant red mass of the maxillary alveolar ridge in the area of the previous graft (second quadrant, teeth 25 and 26). Flexible rhinofibroscopy revealed a total nasal obstruction of the left side with a bulging of the lateral wall of the nasal fossae. The computed tomography (CT) reported a left maxillary rhinosinusitis, the lysis of the left lateral bone wall, and the migration of the alveolar bone graft into the maxillary sinus (oroantral fistula due to bone defect; Figure ). The giant red mass in the oral cavity consisted of the bulging of the Schne", "role": "user" }, { "content": " iderian membrane. The surgical treatment of the patient consisted of: (a) the removal of bone graft from the maxillary sinus through middle meatotomy (functional endoscopic sinus surgery approach; FESS), (b) the washing of the maxillary sinus cavity, (c) the removal of two of the three dental implants, (d) the closure of the oroantral fistula with a Bichat flap. These procedures were made in the same operative time. Regarding <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 32-year old female patient came to the emergency room with the chief complaints of right side LBP, buttock pain, and lower leg pain, which began two days before the visit and became worsened on the day of the visit. The patient was without any particular trauma history and mentioned that the symptom started after she had walked a long distance the previous day. The patient expressed the symptom as a \"twinge\". The pain was weak when in the supine position, but it was aggravated when rising up or moving, so that the patient could not carry out the movements and activities of daily living. A pertinent part of the patient's history was that she had received conservative treatments in another hospital for right LBP and right radicular leg pain, six months before the visit. The computer tomography (CT) image taken at that time appeared to show that the patient had a herniated intervertebral disc at the 4-5th lumbar spine and spondylolysis at the 5th lumbar spine. According to the physical examination,", "role": "user" }, { "content": " right radicular leg pain was developing <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 35-year-old white female who was an elite endurance athlete training for triathlons had a 3-year history of chronic left hip and groin pain which was subsequently investigated by MRI study. Her MRI of the hip and femur incidentally showed distention of the left common and external iliac veins with associated deep vein thrombosis.\nAt the time, she had no symptoms of leg pain or swelling and had no personal or family history of prior thrombotic events. She had a history of prolonged flights; ho", "role": "user" }, { "content": " wever, none were taken immediately prior to <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 32-year-o", "role": "user" }, { "content": " ld parturient, Gravida 2, Para 1, came <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 70-year-old man who complained of nausea, vomiting, and weight loss was referred to our hospital for examination and treatment. He had a history of hyperthyroidism, diabetes, hypertension, osteoporosis, infectious uveitis, and retinal detachment. Computed tomography revealed thickening of the gastric wall from the gastric body to the prepyloric region, as well as retention of food residues (Fig. ). Esophagogastroduodenoscopy revealed friable and irregular mucosa, and a depressed lesion extending from the gastric antrum to the lower body (Fig. ). An esophagogastroduodenoscopy biopsy revealed poorly differentiated adenocarcinoma (por) (Fig. ). Surgery was performed for preoperative diagnosis of undifferentiated advanced gastric cancer. Total gastrectomy was initially planned but then was abandoned during the operation in favor of gastrojejunostomy because of a strong adhesion to the head of the pancreas. Systemic chemotherapy with the SOX regimen (S-1, 120 mg/day on days 1–14; oxaliplatin, 170 mg on day 1) was initiated as treatment because the patient tested HER2-negative in immunohistochemical staining.\nAfter cycle 1 of oxaliplatin infusion, the patient realized that his right eye had visual field impairment, which he described as darkening of the right half of his visual field and loss of vision lasting about 1 min and occurring about 7 times a day. The daily frequency of this occurrence gradually decreased, and his visual field impai", "role": "user" }, { "content": " rment improved in 1 week. No visual field impairment occurred in the left eye. Since the same symptoms recurred from the second to the fifth cycle of treatment, we consulted with an ophthalmologist. An ophthalmologic examination revealed no obvious damage to the retinal and optic nerves. The patient showed no abnormal findings in the brain or around the orbit on magnetic resonance imaging (MRI) (Fig. , b), no stenosis or aneurysm in the internal carotid artery or ophthalmic artery on 3D-MRI (Fig. ), and no plaque or stenotic lesion in the bilateral carotid arteries on carotid artery <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 16-year-old male child was referred to us who had progressed from low grade astrocytoma to gliosarcoma over a long period of 15 years. The child was diagnosed as a case of pilocyti", "role": "user" }, { "content": " c astrocytoma at 6 months of age (in September 2000). The presenting signs and symptoms were progressive increase in head size for 3 weeks with tense and bulging fontanelle, refusal to take feed for 2 days and loss of consciousness for 1 day. CECT scan of head revealed a large cystic space occupying lesion of size 13.7 × 6.7 cm replacing most of the left cerebral hemisphere with an enhancing soft tissue component in its wall suggestive of pilocytic astrocytoma. The infant underwent tapping of tumor cyst followed by left parietal craniotomy and excision of tumor. The postoperative histopathology report showed features suggestive of pilocytic astrocytoma. The child was not planned for any adjuvant radiation and was kept on regular follow-up.\nPatient was referred to our center when he developed presenting complaints of headache on and off with multiple episodes of vomiting and disturbance of gait for 1 month at the age of 16 years. On examination, his Glasgow coma score (GCS) was E4M5V6 (15/15) and power was grade 4/5 in right side upper and lower limbs and 5/5 with normal tone and reflexes on the left side. On further investigation, contrast-enhanced magnetic resonance imaging (CEMRI) of brain showed a well-defined extra-axial collection in left fronto-temporo-parieto-occipital region with nodular thickening of the meninges on the medial aspect of collection displaying intense enhancement on post-contrast images. A patchy ill-defined non-enhancing edema was noted in left temporo-parietal region which was further continuous in the posterior fossa extending into left CP angle compressing and displacing the midbrain and pons towards right. The significant mass effect on the left lateral ventricle with midline shift towards right was seen. CECT scan <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 57-year-old man with a history of alcoholism and heavy smoking was admitted for disabling back pain. Four months earlier, he had sustained two vertebral fractures (T10 and T11) due to falling; these were treated by kyphoplasty under computer tomography (CT) guidance. Because the back pain persisted 2 weeks after the procedure, he received a zygapophyseal joint steroid injection under CT guidance. Three days later, his C-reactive protein level was 12.5 mg/l and hyperleukocytosis was moderate (13 G/L including 10 G/L neutrophils) and the patient had no fever. Magnetic resonance imaging (MRI) findings revealed infectious spondylodiscitis (Fig. ). A Staphylococcus saccharolyticus isolate was recovered after 90 h of incubation from one single vial of a first series of three blood culture (BC) sets. The same microorganism was identified from two additional BC series collected 5 and 10 days later after 83 and 100 h of incubation, respectively. It was not possible to perform either culturing or molecular diagnostics using the tissue sample as the patient’s condition did not permit disc biopsy. However, the findings from the blood culture tests indicated a definite diagnosis of spondylodiscitis, though a catheter or spinal device was not inserted in the patient. Using disk diffusion assay, the isolate was multi-drug susceptible including to penicillin and cefoxitin. The patient was treated with 2 g of amoxicillin three times a day for a total duration of 4 weeks after consultation with the infectious disease team. Pain and inflammatory syndrome both gradually regressed, and MRI performed after 12 month showed decrease in hyperintensity (Fig. b). No clear source of the bacteria was identified. The infection was presumably from skin and the bacteria was likely introduced in the surgical site during the kyphoplasty procedure. However, we could", "role": "user" }, { "content": " not identify any defect in the surgical skin preparation and infection control procedures as well as <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The proband was a 34 year-old right-handed man. From the age of 26 years, involuntary movements of the bilateral lower limbs, associated with dysarthria, grinding teeth and droo", "role": "user" }, { "content": " ling, appeared and gradually worsened. At 31, he suffered from epileptic seizures, which were considered to be generalized tonic-clonic seizure, but antiepileptic drugs had never been administered. One year later, involuntary movements spread to his upper limbs and orofacial automatisms including abnormal tic-like facial movements, tongue protrusion and biting his lips appeared. Then he was treated with haloperidol (2 mg three times a day) and baclofen (10 mg three times a day) for 2 years for his choreic and dystonic problems, but he responded poorly to drug treatments. At age of 34, his involuntary movements gradually spread to his whole body and epileptic seizures increased in frequency. Since the disease onset, the patient had never suffer from psychiatric problems. Neurological examination revealed poor muscle tone and absent deep tendon reflexes in all limbs. Additionally, right positive babinski sign was elicited. Laboratory data revealed elevated creatine kinase level in the peripheral blood. Acanthocytes were found in 4% of cells on the peripheral blood smear test. Doppler ultrasound examination revealed splenomegaly. Brain magnetic resonance imaging (MRI) showed progressive, symmetrical, mild atrophy of the caudate heads (Figure ). His 24-h continuous electroencephalography (EEG) showed generalized asynchronous theta and epileptiform activity, which mostly originated from the right temporal lobe. A nerve conduction study showed a polyneuropathy, which revealed the right peroneal nerve, right median nerve and bilateral ulnar nerves were partly damaged. His score of Mini Mental Status Examination (MMSE) was 27. The father of the proband did not show any neurological abnormalities and died from pneumonia at 65 years old (Figure ). The mother of the proband (II-3), a 65-year-old woman, showed mild involuntary movements in her limbs since the age of 45 years (Fig <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 32-year-old Turkish man was admitted to the emergency department because of severe intrascapular back pain, an episode of unconsciousness and weakness of both legs. Bilateral proximal muscle weakness of the lower extremities had started approximately 4 hours before admission and progressed rapidly. Three hours after appearance of the weakness the patient collapsed and was unconscious for 2 minutes, accompanied by urinary incontinence. No seizure was observed. After regaining consciousness he complained about severe intrascapular back pain, stabbing in nature without radiation. Initially the blood pressure was 80/60 mmHg, the heart rate was 100 bpm and the blood glucose level was 223 mg/dl. Emergency treatment with rapid infusion of cristalloid fluids was started and the patient was transferred to the hospital. When the patient arrived at the emergency department the blood pressure was 110/60 mmHg and the heart rate was 120 bpm. On his trunk and arms were confluating erythematous patches which appeared 3 days ago. Body temperature was normal. His muscle strength was found to be 2/5 on the MRC scale (Medical Research Council Paralysis Scale) in both lower extremities and 3/5 in both upper extremities. The deep tendon reflexes were somewhat diminished, otherwise neurological and physical examination were normal. He smoked 50 cigarettes a day and his alcohol intake was moderate. The family history was negative for cardiovascular disease. Beside nephrectomy after traumatic kidney rupture in childhood no relevant previous disease was present and no previous muscle weakness was noticed. However he reported that he consulted his GP the same morning for treatment of the erythem", "role": "user" }, { "content": " atous patches. The GP gave him a pulse i.v. corticosteroid <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 33-year-old otherwise healthy female was admitted to our hospital initially for symptoms of generalized abdominal pain for 2 days, worst in the left lower quadrant and associated with diarrhea and fever. There was tenderness on palpation associated with rebound but without guarding. Vag", "role": "user" }, { "content": " inal and rectal examinations were unremarkable, without any tenderness or discharge. She was hypotensive with a blood <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 12-year-old male patient visited the outpatient department with chief complaint of an oversized protruded tooth in the maxillary right anterior teeth region. The patient reported that no other individual in the family had this type of anomaly and there were no anomalies found in the deciduous dentition or any history of trauma. General examination of the patient did not reveal any other associated abnormalities. Intraoral examination revealed the presence of mixed dentition stage. The tooth number 11 had a wide crown and showed the presence of a notch on the incisal edge along with prominent mamelons []. The macrodontic incisor measured 15 mm mesiodistally at the midcoronal level and 8.5 mm cervicoincisally. Lingual examination revealed an accessory cusp-like structure, resembling a talon cusp extending from cervical margin of 11 towards its incisal edge measuring 5.5 mm cervicoincisally. Non carious developmental grooves were present at the junction of the talon cusp and the palatal surface of the tooth []. The maxillary central incisor on the contralateral side appeared normal in dimensions but was in crossbite with mandibular left central incisor []. The maxillary lateral incisor on the affected side had erupted palatally []. The number of teeth remained unaffected in the segment. Mandibular anterior segment also revealed marked crowding. The affected tooth responded normally to pulp vitality test. Intraoral periapical radiograph revealed the presence of a large anomalous tooth, which was superimposed by lateral incisor palatally []. The maxillary lateral incisor on the affected side was extracted as part of the treatment plan. The intraoral periapical radiograph then revealed two roots with individual pulp canals. The Orthopantomograph also revealed an impacted supplemental tooth on the contralateral side []. Therefore, based on the clinical and radiographic findings, the case was diagnosed as talon cusp associated with fusion (syndontia) between right maxillary central incisor and a supplemental tooth.\nAfter extraction of maxillary right lateral incisor on affected side an orthodontic ", "role": "user" }, { "content": " appliance <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 27-year-old male patient was admitted to the emergency room of this hospital with shortness of breath that started a week before admission. A chest x-ray performed at emergency room showed a left-sided pneumothorax (Fig. A), and the patient was referred to the department of thoracic surgery. The left lung of the patient was totally collapsed, and there was a high possibility of REPE upon chest tube insertion with the symptom onset of a week. Accordingly, after explaining this situation to the patient and his caregivers, a 12 French trocar tube was inserted into the left thoracic cavity of the patient. In order to allow the lungs to expand slowly, natural drainage was performed without suction, and the rubber tube connecting the chest tube and the water seal bottle was partial clamped. On the day after chest tube insertion, there was an finding of air leakage through the chest tube, but the lungs were not found to expand much as a result of chest x-ray (Fig. B), thus the partial clamped rubber tube was de-clamped. However, about an hour after de-clamping, the patient suddenly complained of severe respiratory distress, cough with foamy sputum, and vomiting. Immediately the chest tube was clamped to stop drainage. With oxygen saturation measured 75%, oxygen was administered to the patient via an oxygen mask, but no improvement was observed. In turn, a chest x-ray was followed during additional high flow nasal prong (HFNP) therapy, exhibiting REPE findings such as newly developed ill-defined consolidation in the left lung (Fig. ). Oxygen saturation did not improve even after HF", "role": "user" }, { "content": " NP therapy, and further, persistent cough with foamy sputum, shortness of breath, and a drop in blood pressure occurred. With the need for intensive care recognized, the patient was immediately transferred to the intensive care unit and then was sedated and intubated to perform mechanical ventilation. After supportive care including mechanical ventilation, the condition of the patient was improved <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 21-year-old male was being investigated for an acute onset of pain involving the left hip for 6–8 weeks. The magnetic resonance imaging revealed a permeative lesion inv", "role": "user" }, { "content": " olving the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A female 83 years old patient presented with progressively worsening dyspnea started in the previous 3 days a", "role": "user" }, { "content": " ssociated with orthopnea, and without chest pain. After initial cardiologic screening, and with an abnormal ejection fraction (EF) value, <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "During anatomic study of the abdominal cavity, additional renal branches from the aortic axis were revealed in a 97-year-old male Caucasian cadaveric donor. Continued dissection outlined notable anatomic variations in the arterial, venous, and ureteric patterns. No urologic or cardiovascular issues were reported by the donor or family at the time of enrolment in the Deeded Body Program. For this type of study, Institutional Review Board approval is not required for research conducted with cadaveric specimens.\nBoth kidneys were retroperitoneal and similar in size with measurements of 12.3 cm (l) and 12.7 cm (r) in the craniocaudal direction. Despite the fact that the lengths were similar, there were marked differences in the relative positioning of the superior and inferior poles. The superior pole of the right kidney was situated more superiorly. The inferior pole of the left kidney was positioned near the superior border of the left common iliac artery. Although each kidney occupied an extended volume, neither kidney had a pelvic component. Hilar structures entered/exited the organs anteriorly, not with the typical medially projected hilum ().\nA total of five major arteries (3l and 2r) emerged from the aortic and common iliac axes (Figures and ). The superior left renal artery originated from the abdominal aorta and supplied the superior pole. This artery", "role": "user" }, { "content": " (5.2 mm diameter) branched into two vessels of similar caliber to supply the upper third of the organ. Supply to the left gonad originated from the more inferior of these two branches (Figures and ). The middle left renal artery (6.1 mm diameter) originated from the iliac junction, just anterior to the median sacral artery (Figures and ). The inferior left renal artery (5.4 mm diameter) originated from the common iliac artery, and coursed posteriorly to the kidney before entering the hilum anteriorly (from the lateral aspect of the organ), to supply the inferior pole (Figures , , <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 6-month-old Chinese male child was admitted to our department with recurring episodes of hypoglycemia for 6 months. His parents were healthy and not consanguineous, and his family history was not notable. The child was first admitted to the hospital because of repeated cyanosis and poor reaction at the age of 2 days. He was diagnosed with hypoglycemia based on his blood glucose level (which was 0.3 m", "role": "user" }, { "content": " mol/L) and recovered after receiving glucose and glucocorticoid infusion. At the age of 22 days, <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 49-year-old man presented with a history of chest pain and worsening breathlessness over the previous 3 days. He had a history of hypertension and smoking. On arrival he had on-going chest pain and was in mild pulmonary oedema. He was Kilip class II with a systolic blood pressure of 120 mmHg. His ECG showed a late presenting anterior STEMI with Q waves and a bedside echocardiogram demonstrated moderate to severely impaired LV function with anterior wall hypokinesia. A coronary angiogram demonstrated a chronic occlusion of the right coronary artery with an ostial occlusion of the left anterior descending (LAD) artery ().\nA standard workhorse wire was taken to the distal LAD with no restoration of flow. A 2.5 x 15 mm balloon was inflated at the site of occlusion (). The next image showed retrograde thrombus embolisation into a large obtuse marginal branch (). This was accompanied by a drop in blood pressure requiring IV metaraminol and rapid deterioration to pulseless electrical activity (PEA) arrest. Cardiopulmonary resuscitation was initiated, an AutoPulse® device applied, and the patient was intubated. A second wire was passed to the circumflex vessel and after predilatation a 3.0 x 28 mm drug-eluting stent (DES) was deployed with a further 3.0 x 38 mm DES deployed in the LAD. Despite TIMI 3 flow in both vessels (), there was no return of spontaneous circulation and resuscitation was discontinued after 38 cycles of CPR.\nThis case demonstrates retrograde thrombus embolisation into a non-culprit vessel with a large amount of myocardium at risk due to chronic occlusion of the right coronary artery. To our knowledge, there are only two other published case reports in the litera", "role": "user" }, { "content": " ture. However, the outcomes are poor. This case highlights some technical considerations hat could have been considered, including passage of a second wire to the circumflex artery, thrombus aspiration upfront (with deep intubation of the guide catheter), use of glycoprotein <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 64-year-old male, two years status-post orthotopic heart transplant for ischemic cardiomyopathy, presented with an agminated cluster of deep red-to-brown firm, indurated erythematous nodules on his left hip and groin (). The patient’s immunosuppressive medications included mycophenolate sodium 1440 mg and cyclosporine 175 mg. He had no constitutional symptoms at the time. The patient was referred to dermatology for evaluation, and the lesions on his left buttock and hip were biopsied (). Pathology results showed a diffuse interstitial infiltrate of atypical lymphoid cells that were large and pleomorphic with mitotic figures. Immunohistochemistry staining of the atypical cells was positive for CD4 and CD30. Stains for S-100, pancytokeratin, myeloperoxidase, and CD56 were negative. The biopsy was consistent with a CD30+ lymphoproliferative disorder. A PET-CT was done and was negative for nodal disease or other foci beyond the primary lesions on the hip. Flow cytometry and T-cell rearrangement studies were performed on the patient’s blood. These results were negative for clonality and only notable for a depressed CD4 to CD8 ratio. Given these findings, immunosuppression was reduced with mycophenolate sodium decreased to 360 mg and prednisone 7.5 mg/day was added. The patient underwent radiation therapy with a total of 4600 Gy of radiation to the affected area. However, during the course of radiation, he developed new lesions in his left popliteal fossa and ankle. His immunosuppressive regimen could not be lowered further due to risk of graft rejection. A repeat biopsy was performed of the newly developing lesions. This also showed a CD30+ lymphoproliferative disorder with signet ring cell features (). The dermis contained a dense infiltrate of enlarged mononuclear cells organized in nodules, cords, and strands embedded in a sclerotic stroma. No lymphocytes w", "role": "user" }, { "content": " ere highlighted <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "Herein we report the case of a 50", "role": "user" }, { "content": " -year-old man, without past medical history, presented to our department of gastroenterology with abdominal pain and constipation for 3 months. The abdominal pain was not colicky but progressive and radiated to the epigastric region and relieved spontaneously without analgesics. No similar cases were mentioned in the family, neither any genetic syndrome nor malignancies. No drug history, nor professional exposure were noticed. There was no reported history of vomiting, diarrhea or passage of dark-colored stool and neither weight loss. At physical examination, there were no palpable masses and no collateral findings on the abdominal wall. Biological tests and blood tumor markers were normal. Endoscopy revealed a sessile polyp in the right colonic angle. Biopsy concluded to a tubular adenoma with low-grade dysplasia. The CT scan showed that the mass was measuring 4 cm in greatest diameter, polypoid with a large base (). No other polyp were identified. The patient was transferred to the general surgery department and underwent right hemi colectomy under general anesthesia, by a well-experienced surgeon specialized in operative management of colorectal carcinomas. The surgical procedure turned good without complications, such as hemorrhage, occlusion or peritonitis. On gross examination, the mass was polypoid with a white lobulated surface and large implantation base (). Microscopically, an invasive adenocarcinoma was identified occupying the colonic mucosal with an invasion of the submucosa (). The tumor showed a tubule-villous pattern on the surface and was made mostly of jagged crowded glands in the depth. Some region exhibiting Paneth cell differentiation characterized by an abundant cytoplasm (low nuclear: cytoplasm ratio) containing bright eosinophilic coarse granules and centrally located nuclei (). The transition between the two patterns was gradual with few glands featuring both Paneth cells and mucin secreting cells.There were no specific distribution of Paneth cells, which were observed both on the surface, and in the depth of the tumor. Masson’s trichrome stain highlighted the dense granules within <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 71-year-old South Asian man who had under gone a right hemicolectomy for an adenocarcinoma of the colon was found to have a metachronous cancer in the sigmoid colon during surveillance colonoscopy. Following his primary surgery at another institution, he has developed an anastomotic leak during the immediate postoperative period, for which a second laparotomy had been performed on day 5 with a revision of the anastomosis. During the first postoperative week, he had developed an enterocutaneous fistula with primary wound failure. His case was then taken over by the authors for the management of the fistula, which was done nonoperatively. Spontaneous healing of the fistula took 10 months, after which the patient underwent an abdominal wall reconstruction with an inlay polypropylene/polyglactin 910 composite mesh. The reconstruction was done 16 months after the primary surgery, and the mesh was fixed using polypropylene sutures. The patient remained asymptomatic until he was diagnosed with a sigmoid cancer on the basis of surveillance colonoscopy 5 years after the primary event. Following histological confirmation and staging with contrast-enhanced computed tomography, he was scheduled for laparotomy with subtotal colectomy and ileorectal anastomosis. During surgery, several loops of bowel were found to be tightly adherent to the anterior abdominal wall. On palpation, a hard, elongated mass was felt inside one of the bowel loops in the proximal ileum. After separating the loops from the posterior rectus sheath, an enterotomy was made to find the mesh inside the bowel lumen (Fig. ). The mesh was not adherent to the bowel wall and could be", "role": "user" }, { "content": " extracted without difficulty. It was heavily deposited with fecal matter, indicating that it had been in the bowel lumen for a long period (Fig. ). There was no evidence of an abscess, fistula, or sinus formation in the surrounding area. The enterotomy was closed with a side-to-side stapler anastomosis, and the patient underwent subtotal colectomy with ileorectal anastomosis with an uneventful recovery. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 45-year-old male motorcyclist with a history of hypertension, hyperlipidemia, and coronary artery disease was brought to the emergency department after being struck by another car on the highway at speeds of at least 40 miles per hour. Upon presentation, the patient was evaluated using Advanced Trauma Life Support (ATLS) principles. He had a patent airway on arrival and was breathing spontaneously on room air. His initial heart rate was 87 beats per minute, and his blood pressure was 124/63 mmHg without signs of significant hemorrhage. He had an initial Glasgow coma score (GCS) of 15 with equal and reactive pupils. The patient admitted to consuming alcohol and had a serum alcohol of 243 mg/dL. A later CT of the head demonstrated a subcutaneous hematoma without any intracranial abnormalities. His remaining physical examination revealed left lower quadrant abdominal pain without signs of peritonitis, ankle deformities bilaterally, pain with hip range of motion, and blood at the urethral meatus. Given his physical examination findings, subsequent imaging confirmed an unstable pelvic fracture with diastasis of the symphysis pubis of 6 cm, widening of the left sacroiliac joint, a left ischial pubic ramus fracture, and a urethral injury (). He also had a left ankle dislocation and a right compound fracture of the distal tibia and fibula. No intraabd", "role": "user" }, { "content": " ominal injuries were identified on CT imaging of the abdomen. The pelvis was stabilized with a binder <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 43-year-old lady without significant co-morbidity and no apparent cardiovascular risk factors presented to us for a second opinion following an emergent admission to her local hospital department with sudden onset central chest pain and ECG changes indicative of acute anterior myocardial infarction (AMI). After initial supportive medical therapy and improvement of her acute symptoms, investigations to further characterise the nature of her coronary disease were performed. CT coronary angiography showed the culprit lesion was likely to be an embolic occlusion of the distal left anterior descending (LAD) artery after the second diagonal branch, but incidentally made note of a soft tissue mass seen on the left coronary cusp of the aortic valve (AV) (Figure ). Further characterisation of this lesion by both trans-thoracic (TTE) (Figure ) and trans-oesophageal echo (TOE) showed appearances consistent with a papillary fibroelastoma (PFE) and she was admitted for surgery on the 24th October 2011. A minimal access 6 cm skin incision was made, and the chest entered via a limited upper sternotomy extending to the right 3rd intercostal space. Cannnulation was performed via the ascending aorta and right atrium (Figure ). Following transverse aortotomy, the aortic valve was inspected revealing a round mass at the very edge of the left coronary cusp. The lesion w", "role": "user" }, { "content": " as excised, sparing the AV, and the valve tested confirming perfect competence prior to closure. Total cross clamp time <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 9-year-old girl was referred to our center with an Ewing sarcoma of the proximal humerus. Initially, she underwent curettage and cementation at an outside center for a pathological fracture of what was thought to be a benign cyst. The tumor progressed, and a biopsy showed Ewing sarcoma, which was confirmed by FISH for EWSR1 rearrangement, involving the proximal humeral metaphysis and epiphysis (Figure ). She was treated with neoadjuvant chemotherapy consisting of vincristine, cyclophosphamide, doxorubicin, ifosfamide and etoposide, and proton radiation therapy because of the soft-tissue contamination. A FVET was planned supplemented with a fresh frozen allograft and rotator cuff.\nThe proximal humerus was approached using an extended deltopectoral approach, and an intra-articular resection of the proximal humerus was performed (Figure ). The tendons of the rotator cuff cut at the myotendinous junction and tagged for repair. Owing to the previous nononcologic surgery, the anterior half of the deltoid and accompanying axillary nerve were resected. A FVET was harvested with the anterior tibial vessels. The articular surface of a cadaveric proximal humerus was removed with a saw, and the cancellous bone of the metaphsysis was removed with a burr to the cortical bone to allow for fitting of the fibular head, whereas the diaphysis was reamed to allow for the FVET to be intussuscepted within the humerus allograft with the articular surface of the fibula facing the glenoid at the level of the tuberosity. A window was created for the vascular pedicle on the medial aspect of the allograft. The anterior tibial artery was anastomosed to a side branch of the profunda brachii artery and vein. The distal e", "role": "user" }, { "content": " nd of the fibula was intussuscepted into the remaining host distal humerus, and the allograft was <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 17-year-old male with complete transposition of the great arteries, ventricular septal defect, and pulmonary stenosis had previously undergone a Rastelli repair with placement of a 16 mm pulmonary homograft in infancy. He subsequently underwent conduit replacement with a 20 mm aortic homograft at 7 years of age that was then balloon dilated at 12 years of age. A transcatheter Melody valve was placed within this homograft soon after balloon dilatation. He did well for 5 years following Melody valve implantation with minimal gradient across the conduit and no more than mild regurgitation. He presented w", "role": "user" }, { "content": " ith a 2 days history of <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 3-year-old definitely negative behavior female child reported to the department of pediatric and preventive dentistry with a chief complaint of pain and fractured right primary maxillary central incisors. Her medical history was not significant and dental history revealed that discoloration of maxillary incisor was seen a few years ago, and chipping of the tooth has occurred progressively, leading to loss of complete coronal structure. Intraoral examinations revealed that right maxillary central incisor is caries extending up to the cervical third with an exposure of the pulp chamber, restored and pulp therapy done 54, dental caries in 51, 61, 62, and 64. Orthopantomogram confirmed the clinical findings and presence of permanent teeth. Pulpectomy followed by intra-radicular biological post and core with crown was planned for 52; restoration of 51, 61, 62, and 64; and stainless-steel crown for 54.\nExtracted root stump is placed in", "role": "user" }, { "content": " a <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 22-year-old previously unsupervised primigravida was referred to the emergency department of our institute from a peripheral hospital at 40 weeks and two days of pregnancy in obstructed labor. She had been in labor for the last 36 h and had been leaking per vaginum for the last 24 h. She had been handled by an untrained attendant in a village for ~20 h before referring to the index peripheral hospital. There was no history of instrumentation. At presentation, she was dehydrated and pale, pulse rate was 120/min, blood pressure 100/70 mmHg and had mild tenderness in the lower abdomen. There was a si", "role": "user" }, { "content": " ngle <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 40-year-old male presented to the ENT outdoor clinic with complaints of a foreign body sensation in the throat, progressive hoarseness of the voice and difficulty in breathing since the last 7 days. The patient developed the above mentioned symptoms after an acute episode of seizure. He also gave a history of five such episodes in the last two years, but he was not on any treatment for seizures. The patient was using an artificial denture for the upper jaw since one year. The patient became unconscious for 5-10 minutes after the last episode of seizure, after which he could not find his denture. He realized that he had accidentally lost his denture during the episode and ignored the whole event. Subsequently he had sudden onset of foreign body sensation in the throat and, later on, he developed progressive hoarseness and difficulty in breathing for which he consulted our hospital. The patient complained of throat pain, painful swallowing and difficulty in speaking associated with discomfort in the throat. There was no hemoptysis or chest pain. During clinical examination, the laryngeal contour was normal and crepitus", "role": "user" }, { "content": " was present. There was no stridor or chest indrawing. Examination of the oral cavity and <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 36-year-old male patient reported to the Department of Oral and Maxillofacial Surgery with a chief complaint of pain in the mandibular right posterior teeth for 8 days and swelling on the right side of his face for 5 days. The patient was a known hemophiliac (hemophilia A) with history of multiple factor VIII transfusions for joint bleeds in extremities. On local examination, a diffuse, firm, board-li", "role": "user" }, { "content": " ke, tender swelling was present on the right lower <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 75-year-old lady presented to our emergency room after a trivial fall and severe pain in her right thigh and inability to walk. There was a history of BP intake for the treatment of osteoporosis for 5 years duration. There was no history of prodromal thigh pain. Radiographs of the right femur showed a complete fracture of the right femur shaft at the isthmus with the transverse lateral cortex, medial spike, and increased cortical thickening suggestive of atypical nature of this fracture (). As per the criteria given by the Task Force of ASBMR, the patient had all major and minor criteria except that the patient had no prodromal symptoms and bilateral association (). These signs led to a diagnosis of Atypical fracture of the femoral shaft. The radiograph of the contralateral femur showed no signs of an incomplete fracture. Subsequently, BP was stopped and the patient underwent closed intramedullary nailing with post-operative radiograph showing acceptable reduction and stable fixation (). Postoperatively, the patient was started on active exercises and non-weight-bearing with a walker on day 1, and subsequently, the patient was discharged on day 3. The radiographs at 3months showed evidence of callus formation, and the patient was advised weight-bearing walking. Subsequent radiographs at follow-ups showed slow healing of the fracture with minimal callus formation. At 9 months, the patient again presented to the emergency room with thigh pain after getting up fro", "role": "user" }, { "content": " m sitting position. Clinical examination showed varus deformity of the right thigh with radiographs showing refracture with segmental breakage of the nail at the level of fracture and distal bolts with minimal callus formation (). This led to the impression that the AFF in the diaphyseal region did not unite in 9 months. Subsequently, the patient was treated with exposure of the fracture site, removal of the nail, and fibrous union. The sclerotic bone ends were removed until there was punctuate bleeding from the bone ends. The fixation was performed with K-nail and augmented plating, as shown by <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 64-year-old man with an underlying diabetes mellitus type 2, hypertension and erythrodermic psoriasis which is under control with medications presented with progressive bilateral lower limb weakness for 1-week duration. The weakness was extend", "role": "user" }, { "content": " ed up to the knee level and caused him difficulty to walk. He denies any numbness, sciatica or lower back pain. There was no preceding history of fall or trauma and no symptoms suggestive of hyperthyroidism. His list of medications includes oral metformin 500 mg once daily, oral losartan 50 mg once daily, oral nifedipine 10 mg three times per day and oral methotrexate 5 mg weekly. He denies taking any over-the-counter nor traditional medication and only drinks alcohol occasionally. On physical examinations, his vital signs showed a low-grade fever with a temperature of 37.7°C, blood pressure of 148/86 mm Hg, pulse rate of 74 beats/min and respiratory rate of 20 breaths/min. Examination of the lower limb revealed weakness over the knee and ankle bilaterally with the muscle power of 3 over 5. The muscle power over the hips and upper limbs was normal. His reflexes were normal, there were no cerebellar signs present, and all his sensory modalities were intact. Examination over the neck region noted there was a diffuse swelling that was more prominent over the right side, which was not tender, firm in consistency, and move upward with swallowing but not with protrusion of the tongue. His abdomen was soft, not tender, and there was no palpable mass or organomegaly. Examinations of the cardiovascular and respiratory systems were normal.\nInitial blood investigations were taken and showed marked hypokalaemia. Otherwise, blood pH, random blood glucose, other electrolytes, and renal and liver function were normal (as shown in ). In view of the goitre, his thyroid function test was tested and reveals subclinical hyperthyroidism with the thyroid-stimulating hormone level of 0.30 IU/mL (normal range: 0.5–4.95 IU/mL), <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 28-year-old woman was admitted to our hospital due to unstable gait caused by pain in the right hallux, for which she was unable to stretch for over three months.\nThe patient had undergone “resection of ameloblastoma at the right mandible, mandibulectomy, and autogenous right fibula grafting” at another hospital on November 20, 2017. The right lower limb of the patient was wrapped with gauze and fixed with a splint for over 20 d. The patient reported within 20 d that the wrapping was too tight, without any evident pain. The patient started walking with the assistance of a single crutch after the splint was removed, and could walk unaided one month after the operation. However, the hallux toe, as well as the second and third toes of the right foot could not be stretched, with pain in all the toes. Therefore, the gait of the patient was unstable, and she was susceptible to fall. Going up and downstairs was very difficult for her.\nThe patient had no significant medical history, psychiatric history, or history of substance abuse. On admission, the physical examination showed that the patient had clear consciousness, and her mental status was normal.\nA healed scar of approximately 15 cm in length was found at the jaw. Another healed scar of approximately 28 cm in length was found at the posterolateral side of the right calf. No evident swelling was found in the right calf and right foot, and no evident pressing pain was found around the right ankle. The motion of the right ankle was restricted, and the parameters were as follows: Dorsal flexion was about 0°; plantar flexion was about 45°, which was generally normal; the right hallux toe was slightly valgus; the second and third toe joints were flexed and could not be stretched when the ankle joint was in", "role": "user" }, { "content": " neutral position. However, these two toe <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 30-year-old woman first noticed double vision 2 years prior to hospitalization. It had been present periodically, mostly in the evenings, and did not disturb the patient sufficiently to seek medical attention. Three months later she noticed leg weakness with walking difficulties, especially when climbing and walking down stairs, and walking instability resulting in consecutive falls. Six months later weakness of the arms appeared that caused difficulties in washing and combing her hair. After seven months she noticed difficulties in swallowing and nasal speech after prolonged talking. All of these symptoms had a fluctuating course and were more pronounced in the evenings.\nA neurological examination revealed diplopia due to the weakness and fatiguability of the rectus superior and rectus lateralis muscles of the left eye as well as of the rectus inferior of the right eye, moderate weakness of the facial muscles, mild dysphagia with nasal speech, mild weakness of neck muscles, and weakness and fatiguability of proximal limb muscles. Very mild active and percussion myotonia were observed, but the patients had not been aware of it prior to hospitalization. The patient's mother had been diagnosed with DM2 at the age of 48 years and her maternal grandfather had cataracts.\nA diagnosis of M", "role": "user" }, { "content": " G was confirmed in our patient by clear positive results in the neostigmine test and decremental responses in the repetitive nerve stimulation test (RNST) (); these were 43% and 26% in the deltoid and nasal muscles, respectively. Anti-acetylcholine receptor (AChR) antibody titer was elevated (8.8 nmol/L, normal <0.2 nmol/L). A chest CT scan showed a persistent thymic tissue in the upper anterior mediastinum, and a pathohistological examination of the thymus after thymectomy revealed thymic hyperplasia. Electromyography during relaxation demonstrated diffuse episodes of myotonic discharges () in multiple muscles, while during voluntary muscle activity a mild myopathic lesion was revealed by short-duration motor-unit action potentials and early recruitment <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 19 year old male patient weighing 61 kg who had been admitted with ", "role": "user" }, { "content": " 50 cc of paraquat ingestion in an attempt to suicide, was brought to <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 12-year-old female presented with a rapidly increasing mass located over the lower left chest wall and the abdomen. The mass had first been noted in the year 2000, and was confined to the chest wall, and local excision had been done in the same year. Histology had reve", "role": "user" }, { "content": " aled aggressive firbomatoisis and the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 81-year-old Japanese woman with a 2-week history of abdominal distension presented to our hospital for assessment. The patient did not have a past history of malignancy, with only a cesarean section as a relevant feature in her history. Endoscopic examination at a previous hospital revealed the presence of early carcinomas in the stomach and distal esophagus. The patient was referred to our hospital for endoscopic resection.\nLaboratory data, as well as serum carcinoembryonic antigen, squamous cell carcinoma antigen, and cytokeratin-19 fragment levels, were close to normal limits. Endoscopic examination revealed mild granular elevated lesions, with slightly depressed irregular mucosa, extending from the anterior wall to the right wall of the distal esophagus (Fig. ). This irregular mucosa further extended from the anterior wall to the left wall, with the boundary on the oral side being unclear (Fig. ). A superficial elevated tumor-like lesion was also observed in the lower body of the stomach, with a diameter of about 10 mm (Fig. ). Based on the endoscopic biopsy specimen, this gastric lesion was diagnosed as a well-differentiated tubular adenocarcinoma. On the other hand, the preoperative biopsy specimens of the esophageal tumor showed intraepithelial tumor ", "role": "user" }, { "content": " cells, which were isolated or <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 63-year-old woman was admitted on April 2013 with a 15-day history of right upper quadrant pain and fever for a week. She had a known definite clinical diagnosis of HHT based on the presence of all 4 Curaçao criteria (diagnosis of HHT in a first degree relative, recurrent spontaneous epistaxis, multiple typical mucocutaneous telangiectasia, and hepatic vascular malformation), and she had been confirmed to harbor the known familial mutation within the intron 5 of the ALK1 gene.\nNine years before she had presented Staphylococcus aureus bacteremia with hip osteoarthritis. The front door of Staphylococcus had not been clearly identified, but the nose was suspected because of her recurrent epistaxis due to HHT. Hepatic vascular malformations had been discovered by echography with Doppler performed as recommended for the follow-up of HHT in 2006. They had remained stable on CT, asymptomatic, and no abnormality in the cardiac output had been d", "role": "user" }, { "content": " etected until then. She had never presented any other clinical complication of HHT but had chronic sicca syndrome related <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 42-year-old woman with a past medical history significant for juvenile idiopathic arthritis (JIA) on anakinra 100 mg subcutaneous daily and hydroxychloroquine 200 mg twice daily, chronic adrenal insufficiency secondary to steroids, currently on hydrocortisone 20 mg every morning and 10 mg in the afternoon, seizure disorder, and a history of recent culture negative infective endocarditis with subsequent cardioembolic stroke presented from a nursing home after a mechanical fall. Imaging on arrival revealed an age indeterminate C7 vertebral fracture, which was treated with conservatively with a cervical collar and pain control. Shortly after admission, her hospital course was complicated by acute on chronic hypoxic and hypercapnic respiratory failure requiring rescue BiPAP (bilevel positive airway pressure) support and admission to the intensive care unit. The patient became encephalopathic, and arterial blood gas revealed respiratory acidosis with significant carbon dioxide retention of >105 mm Hg. The patient was intubated for impending respiratory failure.\nComputed tomography thorax was performed and showed a left-sided opacification initially treated as a left-sided pneumonia. However, her respiratory status failed to improve despite being on adequate antibiotic therapy, and she failed recurrent spontaneous breathing trials while off sedation. These findings lead to the discovery of significant neuromuscular weakness and the left-side", "role": "user" }, { "content": " d opacification. The opacification was suspected to be due to lung collapse secondary to left-sided diaphragmatic weakness (). On <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 4", "role": "user" }, { "content": " 9-year-old woman was investigated for intestinal dysmotility with symptoms of gradual weight loss, postprandial epigastric bloating, a sense of repletion and vomiting over an 8-month period. Since her teenage years, she had maintained a steady weight of 48 kg, but had lost 6 kg over the last 8 months. Her past medical history was remarkable for symptoms suggestive of Raynaud's syndrome, multi-joint arthralgia and an episode of anorexia 4 years previously. She started to experience symptoms of Raynaud's syndrome nearly 5 years ago when she changed her occupation and started working in the food catering industry. There was no deterioration of the symptoms of Raynaud's syndrome associated with the weight loss. There was no history of recent trauma, surgery, prolonged immobilisation or neurological illness. Her weight loss was gradual. A gastroscopy demonstrated a large residue of fluid and undigested food in her stomach with a dilated duodenum extending approximately 10 cm distal to the pylorus. Duodenal and gastric biopsies were negative. Symptoms of presumed delayed gastric emptying failed to resolve after a trial of prokinetics and proton pump inhibitors and she was admitted with hypoalbuminaemia, hypokalaemia and continued weight loss.\nA CT scan of the abdomen and pelvis revealed a hugely dilated stomach extending to the pelvis. The second part of the duodenum (D2) was dilated proximal to a point of sharp obstruction at the level of the third part of the duodenum (D3). At this point of obstruction, the aorto-mesenteric distance was reduced to 6 mm (Figure ). A CT scan also confirmed the impingement of the left renal vein between the aorta and superior mesenteric artery (SMA; see Figure ). There was no thickening of the wall of the duodenum or extrinsic mass lesion. Sagittal reconstruction of CT images through the mid-abdomen (Figure ) showed that the angle between the SMA and the aorta (SMA-aort <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 28-year-old woman presented with a palpable mass, which had occurred 10 years earlier, in the forehead and the resulting contour deformity. Though the mass caused no pain or headache, the patient wanted the mass excised because of aesthetic concerns. Facial three-dimensional computed tomography confirmed the mass to be an osteoma; thus, surgery was performed under general anesthesia.\nDuring the operation, an endoscope was used with a 30-degree-type angle-vision with a light source. The endoscope was connected to a camera, and the endoscopic images were transferred to a television monitor. At two sites, 1 cm skin incisions were made at 1.5 cm superior to the hairline on the scalp above the forehead. One of these incisions was for inserting the endoscope, and the other was for inserting the surgical instruments (). The incisions were made at the periosteum, and some subperiosteal undermining was performed using a periosteal elevator. When the endoscope was inserted, the dissection continued until the osteoma was seen and the area was exposed. To ensure a large enough operating space, one suture was applied on the skin just above the osteoma, and the skin was lifted. Continuous irrigation helped maintain a clear view. The flexible fiber of the Ho:YAG laser was then inserted. The Ho:YAG laser energy was set at an intensity of 0.8 J at a rate of 5 Hz and with 60 watts of power. As the tip of the endoscopic fiber came into contact with the cranial surface with the frontal osteoma the ene", "role": "user" }, { "content": " rgy was gradually increased, and the osteoma <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 68-ye", "role": "user" }, { "content": " ar-old, right-handed male presented to his primary care physician with several <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 36-year-old male patient with a history of UC for the last 8 years was treated initially with azathioprine and shifted to adalimumab therapy 40 mg administered subcutaneously every other week for the last 24 months. He presented to our emergency room with a history of progressive decrease of vision in both eyes over 10 days. On the day of examination, his best-corrected visual acuity (BCVA) was 20/200 in both eyes. Intraocular pressure was 11 mmHg in both eyes. Slit-lamp examination showed clear cornea and occasional cells in the anterior chambers of both eyes. Dilated fundus examination showed bilateral exudative retinal detachment and optic disc hyperemia. Fundus fluorescein angiography showed bilateral m", "role": "user" }, { "content": " ultiple pinpoint hyperfluorescence at the level of the retinal pigment epithelium in the early phases and late pooling of dye in the areas of exudative retinal detachment, in addition to optic disc leakage and staining. Indocyanine green angiography showed multiple hypofluorescent spots in the early and late frames, in addition to fuzzy choroidal vessels and late widespread punctate hyperfluorescent dots. Optical coherence tomography showed subretinal fluid in both eyes [].\nThe patient was admitted with a diagnosis of initial-onset acute uveitis associated with VKH disease. Uveitis workup including complete blood count with differential, erythrocyte sedimentation rate, electrolytes, blood sugar, blood chemistry, liver function tests, tuberculin test, and chest X-ray all came to be unremarkable. The patient was treated with intravenous methylprednisolone 1 g daily for 3 days, in addition to mycophenolate mofetil 1 g twice/day. Oral prednisone 1 mg/kg body weight was started on the 4th day. Sixteen months after this treatment, his examination revealed completely quiet eyes with a total resolution of exudative retinal detachment and the BCVA reached 20/20 bilaterally []. Adalimumab was discontinued 4 months before the last visit by his treating physician and replaced by tofacitinib (Janus Kinase inhibitor) as the patient developed systemic lupus erythematosus ( <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 46-year-old man with history of asthma was brought into the hospital by ambulance for respiratory distress. He was initially managed in the ICU for status asthmaticus requiring heavy sedation and paralysis. His asthma improved, but his course was complicated by bilateral segmental PE detected on computed tomography angiography (CTA). TTE revealed mild RV dilatation and normal RV function. He was treated with low molecular weight heparin and eventually received a tracheostomy because of respiratory weakness, likely from critical", "role": "user" }, { "content": " illness polymyoneuropathy. While out of the ICU, he underwent placement of a percutaneous endoscopic <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 17-year-old girl presented with complaints of a progressively increasing swelling over the front of her left chest over the previous 5 months. The swelling was not painful, situated just adjacent to her left breast, with no associated shortness of breath. There was no history of trauma to the chest wall. She did not complain of an engorgement of the left breast, nipple discharge, or retraction. There was no family history of similar complaints. On examination, her vital signs were stable. There was a large, hard, non-tender mass, 25×30 cm in size, extending from just below the left clavicle to the 6th intercostal space and from the lateral border of the sternum to the mid-axillary line (). The mass itself was adherent to the chest wall although the overlying skin was not. The left breast had been lifted up by the mass and was not adherent to it. There was no palpable breast nodule, ulceration, nipple discharge, or retraction. There were no palpable lymph nodes. Breath sounds were equal and normal bilaterally. The systemic examination was unremarkable. Chest X-ray showed a diffuse opacification over the mid-lung field extending o", "role": "user" }, { "content": " ver to the lateral chest wall. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 85-year-old Caucasian female presented to the emergency room (ER) with a three-day history of right lower quadrant and periumbilical abdominal pain. Her primary care physician had prescribed oral levofloxacin 750 mg once daily for seven days, for a presumptive diagnosis of diverticulitis. Since antibiotic did not seem to bring about a change in her clinical status, the patient decided to seek help at the ER. She was known to have diverticulosis, severa", "role": "user" }, { "content": " l past episodes of left sided diverticulitis, hypertension, hyperlipidemia, hypothyroidism, esophageal reflux, a hiatal hernia, and chronic obstructive pulmonary disease (COPD). Surgery for the recurrent diverticulitis was not done because of the old age of the patient who preferred to use antibiotics and be on follow-up. On chart review, there was a mention of supraventricular tachycardia but the patient had no recall of its nature and records were not available. She had had a cholecystectomy in 1991 and prior colonoscopies which had revealed extensive diverticulosis throughout her descending and sigmoid colon. Her medication list included omeprazole, levothyroxine, and vitamin D. Of note is the fact that she was not on medications for hypertension, hyperlipidemia, and COPD. She had no known allergies. She had 50 pack-year smoking history but quit 10 years ago. Family history was notable for coronary artery disease in her father who died of an acute myocardial infarction.\nOn exam, her vital signs were found to be normal. The only significant finding was periumbilical and right lower quadrant abdominal tenderness, without rebound, guarding, or rigidity of the abdomen. Initial testing showed mild leukocytosis with all other laboratories including hemoglobin, platelet count, renal, and kidney chemistries being within the reference ranges. Lipid panel was as follows: total cholesterol 212 mg/dL, triglycerides 167 mg/dL, LDL cholesterol 151 mg/dL, and HDL cholesterol 43 mg/dL. Patient was on diet modification for hyperlipidemia and refused any medications for that. An obstructive series ruled <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 42-year-old woman presented to our emergency department with a painful swelling in the suprapubic region persisted for 3 days. She had a history of LC 10 years back at our center for symptomatic gallstones and had no history of comorbidities. The patient had a history of cesarean section twice. She had a pulse rate of 92/min, blood pressure of 110/60 and a temperature of 37.4°C. Physical examination revealed abdominal tenderness in the suprapubic region, right and left lower quadrant, and exhibited signs of peritoneal irritation, muscle guarding and rebound tenderness. Laboratory tests resulted with white blood cell: 15 200/mm3, hemoglobin: 11.9 g/dl, C-reactive protein: 24 mg/dl, and other biochemical parameters were also normal. On oral contrast-enhanced abdominal computed tomography (CT) performed in the emergency room (), the mesenteric adipose planes were inflamed and contaminated. Minimal free fluid was observed in the periphery of the intestinal loop in the pelvic area. At first, it was not stated on tomographic interpretation that there were gallstones in the abdomen. Considering that the patient had signs and symptoms of acute abdomen, she underwent diagnostic laparoscopy. In exploration, it was observed that the small intestines were edematous, the omentum was inflamed in the pelvic region and the omentum was attached to the anterior abdominal wall, bladder and uterus by gato. Since a clear diagnosis could not be made in the patient for etiology, abdomen was opened with a midline incision under the umbilicus. Infected reactive fluid located between the omentum and the anterior abdominal wall and pelvic region was aspirated. Adhesions due to previous cesarean sect", "role": "user" }, { "content": " ions were removed. During the adhesiolysis, stones the largest of which was ~2 cm in size, and abscesses were detected in the omental granuloma/cake (). These stones were thought to remain in the abdomen due to the previous LC. Partial omentectomy with abscesses drainage was performed. The abdomen was <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 68-year-old man underwent an open aortic valve replacement because of severe aortic valve stenosis. The day after the open-heart-operation a revision thoracotomy was needed, because of postoperative", "role": "user" }, { "content": " acute thoracic bleeding, and during the procedure a cardiopulmonary resuscitation was performed. Three days after first surgery <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 4-h-old male newborn presented with complete absence of skin over the anteromedial aspect of both lower legs since birth. The baby was bo", "role": "user" }, { "content": " rn to a 23-year-old primigravida mother via normal <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 21-year-old woman presented with left upper quadrant pain. She underwent routine blood tests and non", "role": "user" }, { "content": " -contrast computed tomography (CT). The blood tests did not <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 80-year-old Chinese woman presented with progressive weakness in the proximal limbs and exercise intolerance for 3 months. She had difficulties in climbing stairs and getting up from a chair and needed to rest after walking about 100 m. Her symptoms continued to worsen. Two months before admission, it was difficult for the patient to raise her arms to collect objects or comb her hair. She could only walk about 10 m unassisted. She also complained of numbness in her", "role": "user" }, { "content": " toes and fingers. She had no ptosis and no difficulty chewing or swallowing. She exhibited no skin <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "We describe a case of an 86-year-old Chinese male, with past medical history of ischemic heart disease, heart failure, type 2 diabetes mellitus, hyperlipidemia, cerebrovascular disease with secondary expressive dysphasia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and osteo", "role": "user" }, { "content": " arthritis of the knees. He also has a history <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 31-year-old male", "role": "user" }, { "content": " developed weakness of both lower limbs and severe low back pain after <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 34-year-old man with KTS and no surgical history was referred to our hospital with\nsevere knee arthropathy that had been worsening over the preceding months. He\nmentioned stiffness of the left knee and inability to perform flexion-extension\nmovements, to the point of being unable to walk on his own, and rated the pain as 10\nout of 10 with poor response to analgesics.\nHis physical examination was remarkable for the significantly larger diameter of the\nleft leg, with extensive palpable varicose veins and changes to the skin consistent\nwith venous stasis. The position of his knee joint was fixed, with movement\nrestricted from 75 degrees in extension to 90 degrees in flexion (). Discrepancies in leg length and\ndiameter were difficult to measure due to flexion contracture. Neurologic findings\nwere normal and while the dorsalis pedis and posterior tibial arteries were difficult\nto palpate, the extremity was well perfused.\nA Doppler ultrasound examination (DUS) showed absence of venous obstruction and\nnormal arterial flow. CT Angiography of the leg evidenced important varicose\ndevelopment of the superficial venous system, increased soft tissue component, and\nbone hypertrophy with marked thickening and cortical irregularity in the fibula and\nthe distal part of the femur. Magnetic resonance imaging (MRI) showed intraarticular\nvaricose vessels as well as intramuscular location in the biceps femoris and\nsemimembranosus and involvement of sciatic nerves, with no alterations of joint\nstructures ().\nThe case was presented to a multidisciplinary committee including vascular and\northopedic surgeons. Based on the benign prognosis and the high mo", "role": "user" }, { "content": " rbidity of surgical\ntreatment, conservative management was chosen as the first option. The patient was\nenrolled on a physiotherapy program, which consisted of attending a rehabilitation\nclinic, twice a week initially and then twice a month after the ninth month of\ntreatment, where he performed strengthening and functional exercises to improve range\nof motion and joint stability <\|endoftext\|>", "role": "assistant" } ]

Subsets and Splits

No community queries yet

The top public SQL queries from the community will appear here once available.