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{
"content": "A 69-year-old Caucasian female, with a past medi",
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"content": " cal history significant for hypertension, came <|endoftext|>",
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"content": "A 64-year-old Caucasian woman referred to our Unit with a 2-month history of a tender lesion on the vestibular gingiva of the posterior left maxillary region. No pain or bleeding associated to the lesion was reported. The patient reported previous history of surgically treated breast cancer. She affirmed a smoking history of 5 cigarettes per day in the last 40 years and occasional alcohol consumption. At the clinical examination, there was a sessile mass of about 1 cm distally to the second molar. The mass was dark red and ulcerated (Fig. ). The consistence was tender; there were no bleeding or pain on palpation. No other lesions in the oral cavity and in the oropharynx, or abnormalities in the head and neck district were reported. CT scan, MRI scan and an incisional biopsy were subsequently performed. Imaging described a 19mm x 15mm x 22 mm mass arising from the posterior alveolar edge of the left maxillary bone, protruding into the vestibule with no signs of bone erosion, or muscular infiltration with regard to the internal and external left pterygoid muscles. No lymphadenopathies were described. The incisional biopsy assessed the presence of a plexiform structured epithelial neoplasm, with basaloid and squamous components; immunohistochemistry showed strong positivity for anticytokeratin antibodies MNF-116, a mild positivity for podoplanin and negativity for calretinin. The overall pattern was suggestive for peripheral ameloblastoma. The patient subsequently underwent the resection of the lesion with surrounding bone tissue and the extraction of the second molar using an intraoral access; a Bichat flap was used for closure. The final pathologic diagnosis was peripheral ameloblastoma, with a plexiform pattern consisting of islands and strands of odontogenic epithelium within a fibrous stroma (Fig. ). The tumor resulted to be strongly positive for CK14 (Fig. ) and diffusely positive fo",
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"content": " r CK19 (Fig. <|endoftext|>",
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"content": "A 74-year-old female retired healthcare worker presented with abdominal pain and vomiting following a left inguinal hernia repair performed 7 days priorly. Symptoms began two days after her surgical procedure. Patient had a ",
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"content": " seven out of ten nonradiating, diffuse abdominal pain localized to <|endoftext|>",
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"content": "A 53-year-old male patient presented with complaints of shortness of breath and chest pain due to severe aortic valve stenosis diagnosed in a local hospital. The patient had a medical history of mitral valve replacement with a mechanical prosthetic valve in 2011. The electrocardiogram (ECG) on admission showed sinus rhythm and findings suggestive of left ventricular hypertrophy, while transthoracic echocardiography showed a heavily calcified aortic valve with an aortic valve area of 0.81 cm2 and peak and mean pressure gradients of 87 and 55 mmHg, respectively. The bileaflet mechanical mitral valve was intact. The left ventricle showed normal systolic function and dimensions with mild concentric hypertrophy. Mild pulmonary hypertension was identified with a right ventricular systolic pressure of 44 mmHg and mild tricuspid regurgitation. Computed tomography (CT) images demonstrated a calcified aortic valve with an annulus diameter that ranged from 23.8 to 25.9 mm, an annulus perimeter of 77.5 mm, and an annulus area of 473.2 mm2 ().The minimum distance between the prosthetic mitral valve and the aorti",
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"content": " c valve annulus was 4. <|endoftext|>",
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"content": "A 39-year-old woman was admitted to the ER with a right-sided drop-foot, fever, and pancytopenia. The patient reported night sweats during the last month and a 25 kg weight loss over the last year. On physical examination, enlarged, painless right cervical and axillary lymph nodes were found; the largest of which was 1 × 2 cm. A CT-scan revealed marginally enla",
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"content": " rged axillary and abdominal lymph nodes as well as <|endoftext|>",
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"content": "A 36-year-old male presented to the outpatient department with a history of low backache for the past one year, associated with typical claudication symptoms, left-sided unilateral numbness, and paresthesia of the foot. He gave no history of radicular pain, but he complained of progressive reduction in claudication distance. He had experienced a sudden deterioration in gait along with urinary incontinence, following a trivial traumatic fall, one week before presentation. There was no history of constitutional features. On examination, he had a bilateral high-stepping gait due to foot drop. Symmetrical weakness of both the L4 and L5 roots (MRC grade 0/5) and partial weakness of the S1 root (MRC grade 3/5) was noted with nondermatomal sensory disturbances. Deep tendon reflexes of the lower limbs were absent bilaterally. Though anal tone was normal, saddle anesthesia was present. Postvoidal ultrasonogram of the urinary bladder revealed a residual urine volume of 250 ml, thus confirming a neurogenic bladder.\nPlain radiography of the lumbar spine did not show any gross feature of instability and was inconclusive (). Magnetic resonance imaging (MRI) of the lumbar spine revealed a solitary intraspinal posterior epidural lesion of 1.8 × 1.5 × 0.5 cm at the L2-L3 level with heterogeneous signal intensities and adjacent epidural fatty hypertrophy contributing to severe canal stenosis (3 mm). The cauda equina was severely compressed and was almost not visible (). Owing to the hetero",
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"content": " geneous signal intensities, computerized topography <|endoftext|>",
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"content": "A 78-year-old female patient was referred to the Dental Clinic of the University of Padua in order to evaluate a painless swelling on the palatal mucosa located near the superior left canine. The lesion, as described by the patient, was first noticed 10 years before. The patient was a nonsmoker and was under treatment for hypertension (with ACE inhibitor, beta blocker, and low-dose aspirin). Oral examination revealed two adjacent lesions, covered with normal coloured mucosa, measuring 7 × 5 × 5 mm and 4 × 3 × 3 mm (). The main lesion appeared as a hard painless gingival swelling with smooth surface; the smaller one was a pedunculated outgrowth of the palatal mucosa with soft consistency. No associated lymphadenopathy was detected. X-ray examinations (intraoral radiograph and computed tomography) showed slight bone resorption in correspondence of the lesion (Figures and ).\nExcisional biopsy of the two lesions was performed under local anaesthesia, and the tissues were submitted to histopathological examination. Microscopic examination of the main lesion showed a mucosal mass covered by stratified squamous epithelium (). The lamina propria contained multiple cords and small islands of epithelial tumour cells with ameloblastic features. The peripheral tumour cells often exhibited hyperchromatic, columnar nuclei with a palisaded arrangement and areas of reverse nuclear polarity. In some areas, the cells of the tumour islands showed an acanthomatous pattern with central squamous differentiation (, left side). Other parts of the lesion consisted of narrow ribbon-like cords that were suggestive of an early plexiform pattern (). The minor lesion also revealed the presence of tumour cells with a desmoplastic pattern, consisting of thin cords (only a few cells in width) of odontogenic epithelium dispersed in a dense collagenous stroma ().\nAccording to the clinical, radiographic, and histopathological exams, a PA was diagnosed. Four months after the excisional biopsy the surgical wound appeared healed by secondary intention. Further surgical approach (a radical resection) was deemed unnecessary and a two-",
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"content": " month <|endoftext|>",
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"content": "A 57-year-old woman presented with signs of inflammation, hardness, and lymphedema, with orange peel appearance of the skin of the right breast. A palpable mass of the right axilla preceded the breast lesion. It was gradually enlarging during a three-month period and did not respond to treatment with antibiotics. A mammography, performed when the axillary mass, was first observed, and it did not detect any abnormality in the breast, except of an enlarged lymph node in the axilla (). Her medical history i",
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"content": " ncluded hysterectomy for a mucinous borderline tumor of the right <|endoftext|>",
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"content": "The patient was a 72-year-old man who was followed up for persistent pain in the left side of the waist for 2 years, radiating to the left hip. The history of schistosomiasis was 40 years, and with hypertension 1 year. On physical examination, he had pain on movement of the spine with bilateral Grade IV motor strength in both lower extremities. There was not numbness in both feet and ankles with normal ankle reflexes bilaterally. There was a normal knee reflex bilaterally. There was no obvious bulge in the bilateral kidney region, and the left lateral kidney region knocks out to be positive for pain. The neurological symptoms were ascribed to the compression of the spinal cord and nerve roots by an expanding mass partly protruding into the vertebral canal.\nMagnetic resonance imaging (MRI) was performed that the left side of the vertebral body and the left",
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"content": " peritoneum showed an elliptical abnormal signal shadow, which <|endoftext|>",
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"content": "A 37 year old man was referred to a district hospital with pectus excavatum and progressive shortness of breath. Native computed tomography revealed an excessively deformed chest (Figure ) and symptoms were thought to be related to the anatomical situation. After presentation of the patient in the thoracic surgery unit, he was scheduled for an operative correction. A Ravitch-procedure had been performed in July 2009. The patient's pectus excavatum was addressed using two metal bars. The",
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"content": " y were placed in a parallel fashion with the ends <|endoftext|>",
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"content": "Coronary artery disease status post coronary artery bypass grafting times 4 with LIMA to the LAD saphenous vein graft to OM1 saphenous vein graft to OM2 and saphenous vein graft to the diagonal . Hypertension . Hypercholesterolemia . Status post partial thyroidectomy . Status post hernia repair . Status post left knee surgery . Status post tonsil and adenoid surgery . DISCHARGE MEDICATIONS 1. Atorvastatin 10 mg q.d. 2. Plavix 75 mg q.d. times 3 months . Aspirin 325 mg q.d. Lasix 20 mg q.d. times two weeks . Potassium chloride 20 mEq q.d. times two weeks . Metoprolol 12.5 mg b.i.d. Percocet 1 to 2 tabs q. 4 hours p.r.n . The patient is to be discharged home with visiting nurses . He is to have follow up in the wound clinic in two weeks and follow up with Dr. Brewster in two to three weeks and follow up with Dr. Rota in 4 weeks . Herbert Jesus Georgia 01835 Dictated By Scott OK Astarita M.D. MEDQUIST36 D 2016-09-14 125227 T 2016-09-14 132805 Job 15604 Signed electronically by DR. Richard Gomez on FRI 2016-09",
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"content": " -16 <|endoftext|>",
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"content": "An 81 year-old-woman visited the department of internal medicine in our hospital complaining of an upper abdominal mass, loss of appetite, and abdominal distention. An elastic and hard tumor was palpated in the right hypochondriac region. Other than hypertension, she had a history of left breast cancer 11 years ago. She had no family history of breast cancer. Left breast-conserving operation therapy along with axillary lymph node dissection and postoperative radiation therapy were performed in May 2000. Histopathological examination revealed invasive ductal carcinoma, including papillotubular carcinoma with pT2N0M0 (pStageIIA). Specific immunostaining revealed results of estrogen receptor (ER)-positive stai",
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"content": " ning of 80%, progesterone receptor (PgR)-negative, human epithelial <|endoftext|>",
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"content": "A 77-year-old man with right renal calculi measuring 1.0 × 0.8 cm underwent primary ESWL with satisfactory efficacy. Follow-up renal ultrasound showe",
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{
"content": " d no remaining calculi. <|endoftext|>",
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"content": "A 53-year-old female was referred to our spine clinic with complaints of chronic neck pain and stiffness; the left arm pain which radiated down the radial aspect of her arm, forearm, and hand; fixed kyphotic posture of the neck; and difficulty swallowing. She reported sustaining a traumatic neck injury 6 years prior when she was an unrestrained front seat passenger in a stolen car. Apparently, she and the driver of the vehicle were under the influence of methamphetamines when they crashed the vehicle into a tree. Both fled from the scene and did not seek medical treatment for fear of legal consequences. She developed immediate neck pain and neck stiffness. Shortly after, she developed electric-like left arm pain which radiated down the radial aspect of the upper extremity. She was homeless, uninsured, and she feared criminal prosecution as she was injured in the act of committing a felony. She began self-medicating to control her neck pain, using heroin, street bought oral opiates, and alcohol. She purchased a soft cervical collar from a local pharmacy and wore it exclusively for several months. Approximately 6 months after the injury, she noted progressive flexed cervical posture with difficulty maintaining forward gaze. Less than1 year after the accident, she was incarcerated in a local correctional facility for repeated drug convictio",
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"content": " ns. <|endoftext|>",
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"content": "A 62-year-old woman presented with a chief complaint of abdominal, back and neck pain. She had developed polymyositis 12 years previously and started taking prednisolone (controlled at 11 mg/day at the visit). She was also taking oral medication for hypertension.\nLower abdominal pain appeared a day after upper gastrointestinal angiography with barium contrast agent. Subsequently, she experienced gradual abdominal, back and neck pain. Chest and abdominal computed tomography (CT) showed mediastinal emphysema and free air in the abdominal cavity. She was referred to our hospital for suspicion of an oesophageal rupture.\nThe patient’s height was 152 cm, body weight was 41 kg, body temperature was 39.4 °C, blood pressure was 160/99 mmHg, and pulse rate was 140 times/minute. Her abdomen was markedly bloated with an overall rebound tenderness.\nOn chest and abdominal CT, free gas was observed in the entire abdominal cavity (), and extensive emphysema was also observed in the retroperitoneum (). In addition, it was observed from the mediastinum to both sides of the necks ().\nColon perforation was suspected from the abdominal findings and the f",
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"content": " inding of free gas in the abdominal cavity. <|endoftext|>",
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"content": "This is the case of a 37-year-old, primigravid woman who underwent spontaneous vaginal delivery. She was deemed to be well before labour with an uncomplicated pregnancy having walked to the delivery unit that morning. She had a normal blood pressure throughout pregnancy as well as in the postpartum period.\nDuring labour, it was noticed that the patient was becoming increasingly confused but hours later she underwent normal vaginal delivery. She was however noted to be still confused by her husband. Twenty-five minutes after delivery, her first generalised tonic-clonic seizure occurred, lasting about 5 minutes before spontaneously resolving. Despite being given magnesium sulphate for possible eclampsia at that time, she remained confused and had a further seizure within 3 hours. A further infusion of magnesium was administered unsuccessfully, thus the patient was given intravenous anti-convulsants causing a decrease in consciousness requiring subsequent intubation for airway protection. She had a one-off elevated blood pressure of 160/102 during fitting, and at all other times she was normotensive. Her urinalysis showed a trace of protein after delivery. Eclampsia was subsequently thought to be unlikely. At the time of the mother's second fit, the newborn baby also had a seizure. Further information from the partner suggested that the couple normally drank a lot of water between them, with the mother drinking up to 4 litres of water a day. The mother had recently been drinking more than this because of the recent hot weather. She also continued to drink increasing amounts of water in the run-up to labour due to a feeling of thirst, after being taught to avoid dehydration in antenatal classes. Liberal fluid intake is encouraged to counter the fluid losses and energy expenditure during childbirth []. There was no other medical or drug ",
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{
"content": " use history. <|endoftext|>",
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[
{
"content": "A 64-year-old woman presented with large varicose veins",
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{
"content": " , CEAP C2s, in the left lower limb. <|endoftext|>",
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"content": "A 9-year-old Caucasian boy of Greek nationality was referred by his orthodontist for assessment of the upper anterior labial frenum (). The medical history was free. The dental history was composed of very minor dental procedures depending on the growth of the child. No allergies reported. The weight of the patient was 32 kg. The height of the patient was 112 cm.\nThe clinical examination revealed the presence of a high frenum attachment pathologically extending to the palatal inter-incisal region. As a consequence this presented a pathological eruption of the upper central incisors laterally, and towards to the canines.\nIt was decided to perform laser frenectomy without infiltrated anaesthesia using specific laser parameters (). The laser equipment was defined by the manufacturer (Lamda Scientifica Srl) as a class-II B device according to the CE conformity statement, and the parameters were 1400 mW at 808 nm with continuous output. The optical fiber used was 300 μm diameter allowing a very fine soft tissue cut. According to the manufacturer, the optical protective glasses had an Optical Density > 5 at the wavelength of emission from the diode. According to standard EN 60825 CEI 76-2 II, the minimum optical density has been estimated to be 4.96 at 0.05 m.\nThe labial frenum was sprayed with lidocaine twice. The laser fiber was applied vertically and laterally to the frenum initially causing disruption of the mucosa continuity. This easily allowed performing a deeper cut of the frenum in a horizontal dimension. The design of the frenectomy was rhomboidal al",
"role": "user"
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{
"content": " lowing easy pass of the fiber-optic between the central incisors <|endoftext|>",
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"content": "A 33-year-old Caucasian male presented to our surgical unit after 3 days of progressively worsening abdominal pain. The patient also reported the onset of constipation for some days, but he denied any associated nausea or vomiting.\nHis past medical history included a right-sided Wilms' tumor treated with unilateral nephrectomy when he was 2 years old. Moreover, during the follow-up for this pediatric tumor, some progressively growing intra-abdominal cystic formations, localized at the level of the mesentery, have been incidentally identified.\nPhysical examination revealed a hypogastric mass and diffuse abdominal tenderness without abdominal distension.\nThe patient underwent an abdominal CT scan () which showed the presence of 3 contiguous and communicating cystic formations located at the level of th",
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"content": " e mesentery that altogether had a major axis equal <|endoftext|>",
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"content": "A 45 years old man presented with one month history of generalized abdominal pain and increasing abdominal distension. Three days prior to admission the pain was worsening in severity w",
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{
"content": " ith associated nausea and constipation. <|endoftext|>",
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"content": "A 28-year-old female presented with history of shortness of breath, cough with blood stained sputum and oliguria for 1 day. There was history of pedal edema, multiple joint pains associated with swelling for 10 days, with history of oral ulcers off and on and polymenorragia for 6-8 months. There was also history of untreated mild to moderate hypertension for 2 years. She was admitted inntensive care unit (ICU) for ventilator support. On examination, Jugular Venous Pressure (JVP) was raised with severe pallor and pedal edema. Auscultation of chest revealed fine crackles all over the chest. Abdominal examination showed hepatomegaly. X-ray and computed tomography (CT) scan of chest showed diffuse alveolar opacities in bilateral upper and middle lobes of lungs. Initial urea and creatinine values were 89 mg/dl and 2.2 mg/dl respectively. Serology revealed positive ANA and anti double strandard DNA antibodies. Patient was diagnosed as SLE with acute flare up in the form of diffuse alveolar hemorrhage and renal failure. Patient was intubated and put on a ventilator, started with pulse methylprednisolone therapy and injection cyclophosphamide. Three units of packed red cells were transfused for severe anemia (Hb-4.7 g/dl). As there was no improvement after 48 h, the treating physician planned plasma exchange for the patient. The patient was assessed for the procedure by transfusion medicine team and the patient was shifted to department of transfusion medicine on ventilatory support. One plasma volume of patient was exchanged with normal saline and 4% ",
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{
"content": " human serum albumin as replacement fluid. <|endoftext|>",
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"content": "A 65-year-old Russian male, not known to have chronic medical illnesses, came to the ED complaining of painful swelling in the lower abdomen which had been going on for five days. Abdominal pain was severe colicky in nature with no relieving factors, associated with nausea and vomiting multiple times. There had been no change in bowel habits, fever or change in appetite. The patient had a history of lower abdominal surgery at the age of two, but he had no medical report\nOn physical examination the patient was conscious and had a normal body built. His blood pressure was 126/92, pulse was 88 and temperature was 36.2 °C. is symmetrically distended with a swelling in the lower abdomen 12 × 15 cm in size with negative cough impulse, erythema and tenderness on the overlying skin. The rest of the abdomen was soft on palpation with positive bowel sounds. Investigation of his hemoglobin gave 10.8 wbc’s with 11.5 sodium 139 potassium 3.2 creatinine 0.7.\nThe patient was admitted as a case of abdominal pain for investigation. The CT of abdomen and pelvic with IV and oral contrast was done showing thickened terminal ileum with marked luminal narrowing which appeared adherent to the urinary bladder wall with no line of cleavage. Two fistula tracts were seen superior and inferior; the superior one lead to a pocket of collection filled by contrast 36 × 20 mm in size. The inferior tract was connected to an anterior abdominal wall collection measuring about 18.7 × 14.4 mm with marginal enhancement deno",
"role": "user"
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{
"content": " ting an abscess. <|endoftext|>",
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"content": "Our patient was a 51-year-old female who presented with a 1-week history of lower extremity weakness and mid-thoracic back pain. The patient had a known history of breast cancer diagnos",
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{
"content": " ed 10 years ago, and was <|endoftext|>",
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"content": "A 31-year-old male developed weakness of both lower limbs and severe low back pain after lifting a gas cylinder. Four days later he was admitted to Adan Hospital. X-ray of the lumbosacral spine revealed simple fracture at L1 and L2 vertebrae and magnetic resonance imaging of the lumbar spine confirmed the fracture. Within the next few days the weakness gradually progressed to 3/5 power in the upper limbs and 0/5 in the lower limbs bilaterally and bilateral lower motor neuron facial palsy. Deep tendon reflexes were absent in all four limbs and the plantar response was mute. He was assessed by a neurologist and was transferred to the ICU as he developed respiratory distress and bulbar weakness. NCS showed prolonged distal latencies with conduction block, prolonged F waves, reduced M-wave amplitudes, reduced nerve conduction velocities and absent H reflexes. Blink reflex was abnormal with prolonged latencies and reduced amplitudes. Routine blood counts and blood biochemistry were normal. Connective tissue disease and porphyria screening were negative. Serological tests for M. pneumonia, Epstein-Barr virus and hepatitis virus were negative. Cerebrospinal fluid study was not done because the patient refused it as he had back pain. The clinical and electrophysiological features were consistent with GBS. He was treated with a course of IVIG (0.4 g/kg/day for 5 days). While in the ICU he developed aspiration pneumonia and septica",
"role": "user"
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{
"content": " emia which was treated by meropenem and ciprofloxacin. <|endoftext|>",
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"content": "A 64-year-old woman presented to the gastroenterologist with abdominal pain, unintentional 10 pound weight loss over 3 months, and reflux symptoms. Pertinent medical history included hypertension treated with olmesartan 20 mg once a day for the past 7 years, hyperlipidemia treated with simvastatin, gastroesophageal reflux disease treated with pantoprazole 20 mg twice a day, and osteoporosis treated with denosumab injections every 6 months. Esophagogastroduodenoscopy (EGD) performed in the office showed granular mucosa in the proximal duodenum and nodular mucosa in the stomach with numerous linear ulcers. On withdrawal of the scope from the duodenum, a large amount of fresh blood was noted in the stomach with clotted blood near the cardia. The bleeding was believed to be due to either the underlying gastric ulcers or a Mallory Weiss tear. The patient was transferred to the emergency department for further evaluation.\nOn admission, the hemoglobin and hematocrit were normal, and an emergent EGD was performed. The gastric fundus and body appeared atrophic with friable and severely inflamed mucosa and multiple linear ulcers without active bleeding (). The antral mucosa appeared erythematous. Biopsies of the stomach and ",
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"content": " duodenum were performed. <|endoftext|>",
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"content": "A 5-year-old female child was brought to us with a right sessile and dense membrane on the right upper eyelid since 1 month after birth. The membrane had previously been removed, and she had received long-term topical steroid treatment in another clinic. Upon examination, we found that she had right mechanical ptosis, esotropia, corneal leukoma, and complicated cataract, possibly steroid induced. The membrane had a firm, fibrous consistency with elevated edges and measured 20 × 14 mm in the right upper eyelid []. There was minimal inflammation in the lower eyelid. Her visual acuity was motion hand-20/20 in her right and left eyes, respectively. The membrane was excised from the upper eyelid. Histopathological analysis",
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"content": " of the removed pseudomembrane showed eroded epithelium with massive <|endoftext|>",
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"content": "A 58-year-old man was found to have intrahepatic and extrahepatic bile duct dilatation on B ultrasound on 12 June 2009, and was hospitalized for further examination and treatment on 20 June 2009. Our patient was 171 cm tall and weighed 86 kg. There was no anemia or jaundice in the palpebral or bulbar conjunctivas. The superficial lymph nodes were not palpable. The abdomen was flat without any palpable mass. He had had diabetes and hypertension that had been under regular medical control for the past 20 years. Abdominal ultrasonography was carried out and a 4.3 × 5.2 cm protruding tumor was found in the lower pole of the right kidney. The laboratory test results showed total bilirubin was 20.6 μmol/l and direct bilirubin was 10.3 μmol/l, the results of a magnetic resonance imaging (MRI) scan showed (1) a lesion in the lower pole of the right kidney, (2) cysts in the left renal area and (3) abnormal signals in the ampulla of Vater. Intrahepatic bile duct dilatation could be seen on the MRI scan, but the head of the pancreas and distal bile duct showed no tumor signals leading to a diagnosis of periampullary carcinoma and right renal carcinoma. Considering the trauma of pancreaticoduodenectomy combined with renal resection operation is greater, and laparoscopic ",
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"content": " resection of renal tumors is feasible with fast <|endoftext|>",
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"content": "A 42-year-old, gravida 3, para 2, Korean woman was referred to the Department of Emergency Medicine at Samsung Medical Center in November, 2014, for abdominal pain and fever. Her past medical history was unremarkable, although she had received myomectomy in 2010 and total abdominal hysterectomy in 2011 at another university hospital due to symptomatic uterine leiomyoma. Unfortunately, the registered medical chart or pathology slides of her previous operation specimens were not available. Therefore, we could not review the previous slides of her previous operation.\nShe had been suffered from abdominal pain since one month ago. Otherwise, there were no urinary or gynecologic symptoms. Even though, she had fever at first, her vital signs relatively stable as follows: systolic and diastolic blood pressure 127 and 76 mmHg, pulse rate 96 beats per minutes, respiratory rate 20 breaths/min, and body temperature 39.1℃. Laboratory test showed no definite abnormal results except for elevated C-reactive protein (25.93 mg/dL). Blood and urine culture results revealed no growth of microorganisms. Routine urine human chorionic gonadotropin (hCG) test for childbearing age women was not performed, because she already had hysterectomy.\nOn magnetic resonance imaging and computed tomography (CT) for the abdomino-pelvic region, there were 9-cm-sized soft tissue like lesion in the midline lower abdominal wall () and another 6.6-cm-sized lesion in the right side of the pelvic cavity which formed a fistula with the distal sigmoid colon. Otherwise, there were no definite abnormal findings on imaging studies.\nThe presumed diagnosis was desmoid tumor or mesenteric sarcoma. Urgent exploratory laparotomy was performed for surgical resection and pathologic confirmation. Midline lower abdominal wall mass was removed by wide excision (). Through exploration, we identified that the distal sigmoid colon was perforated with massive inflammatory changes and had a fistula connected with the right-side pelvic mass. This mass with the distal sigmoid co",
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"content": " lon fistula was removed through <|endoftext|>",
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"content": "A 58-year-old, married, Hindu, unemployed male, a confirmed case of schizophrenia of 30 years duration with no family or past history of psychiatric illness, no history of any medical or surgical illnesses, presented in our OPD with pulling hair and eating the hair root for the last 5 years. There were no positive symptoms but had predominant negative symptoms. Prior to the consultation in our hospita",
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{
"content": " l, he was on irregular treatment with haloperidol. <|endoftext|>",
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[
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"content": "This eighty-year-old gentleman presented to accident and emergency with right arm weakness. The patient reported a sudden onset of right neck pain at rest radiating to his right shoulder and back, leadi",
"role": "user"
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{
"content": " ng to immediate numbness and tingling down <|endoftext|>",
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"content": "A 27-year-old morbidly obese African American, gravida 1, para 0 female presented during the first trimester of her pregnancy with swelling in the right jaw and loosening of teeth. The patient also complained of localized pain but denied fever, weight loss, and other constitutional symptoms. On examination, there was a tender swelling of the right mandible. A biopsy was performed that showed mixed inflammation with numerous foamy histiocytes suggestive of Rosai-Dorfman disease. A CT scan was subsequently performed to delineate the extent of the disease to rule out nodal disease and other possible areas of involvement. The CT scan demonstrated a lytic lesion involving much of the body of the right side of the mandible, extending into the mentum of the mandible and crossing the midline into the ante",
"role": "user"
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{
"content": " rior aspect of the left body of the mandible (). <|endoftext|>",
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"content": "A 53-year-old female presented with complaint of soft tissue swelling on the left side of neck that had gradually increased in size over a 1-year period. Her past medical history is remarkable for left submandibular gland PA treated with enucleation more than 30 years ago. The details of the operative report from this first procedure were not available. On physical examination, head and neck revealed a 4 × 3.5 × 3 cm well-defined-enlarged-multilobulated submandibular gland. No pain or signs of facial nerve weakness or palsy were present. MRI of orbit, face, and neck without IV contrast showed ipsilateral cervical adenopathies and fluid signal intensity lymph nodes. The largest no",
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"content": " de measured 1. <|endoftext|>",
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[
{
"content": "We present a rare case of a 67-year-old male patient admitted to our hospital with a slowly growing mass in the right upper extremity. The patient reported that he fell from a tree 10 years prior to the hospital admission. After a year of injury, the patient had begun to complain of a lump with a gradually enlarging mass in the axillary region. No history of neurological deficit was found. Our physical exam showed a firm, tender, nonpulsatile and immobile mass with unclear boundary and we suspected a primary soft tissue tumor (Fig. ).\nX-ray examination showed destruction of the right proximal humerus with glenohumeral dislocation and a large soft tissue mass surrounding it. An oval-shaped eggshell calcification was also found in the axillary region. Marked erosion was seen at the adjacent glenoid fossa and acromion with sclerotic changes with widening of the glenohumeral joint space. Based on the imaging findings, we suspected a malignant soft tissue tumor with following bone destruction (Fig. ).\nTo better investigate the suspected soft tissue mass, we performed an ultrasound exam followed by an ultrasound-guided fine needle aspiration biopsy. A large soft tissue mass of the right shoulder with multiple cystic hypoechoic foci and deformities of the surrounding bone was found. These findings led to a feature of primary soft tissue tumor (Fig. ). No significant abnormal vascular fill",
"role": "user"
},
{
"content": " ing was found on color Doppler ultrasound; the <|endoftext|>",
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}
] |
[
{
"content": "A 15-year-old boy, grade 9 student, presented in neurosurgery clinic with complaints of backache and left leg numbness. According to the patient’s father, his symptoms started three months prior when he developed pain in the lower back. Symptoms were gradual in onset, continuous and progressively increasing in intensity from moderate to severe. The pain was worse at night and was relieved by taking paracetamol (acetaminophen). It was also associated with weakness in the lower limbs, with a left-sided predominance. A week prior to presentation, the patient developed urinary retention and constipation. His birth and family histories were insignificant. Vaccination and developmental milestones were up to date. General physical exam was unremarkable. Systemic examination revealed decreased power in the lower limbs, bilaterally positive straight leg response and absent plantar reflexes.\nConsidering the presenting complaints and examination findings, the patient was admitted for further workup. Magnetic resonance imaging (MRI) of the whole spine was performed which revealed an intr",
"role": "user"
},
{
"content": " amedullary lesion extending from T8 to <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 33-year-old Caucasian male was transported to the emergency department after a low-speed motorbike accident. He had a free medical record with occasional tobacco use. On presentation, the patient had normal vital signs: Blood pressure: 133/91 mmHg, heart rate: 72bpm, peripheral oxygen saturation (SpO2): 100 %, Temperature 36,8 °C. He complained of deep right upper quadrant and right flank at rest and right upper limb pain, without evidence of ecchymosis or lacerations on his chest or abdomen. Some superficial abrasions were visible on his right elbow and his right lower quadrant. Physical examination revealed mild tenderness to deep palpation in his right upper quadrant and right flank.\nThere were no abnormal signs on his blood analysis, metabolic or coagulation panel. Urinalysis revealed mild microscopic hematuria (20–26 erythrocytes per field vision). Chest, spine and pelvis plain radiography was negative for fractures or any other abnormal findings. A focused assessment sonography for trauma (FAST) performed by a clinical radiologist in the Emergency Department revealed no evidence of trauma. An abdominal contrast-enhanced computed tomography scan (CE-CT) was performed due to persistence of pain and high clinical suspicion. The CT revealed round enlargement of the right adrenal (4.2 × 2.7 cm) with in",
"role": "user"
},
{
"content": " creased density (60-70HU), periadrenal fat <|endoftext|>",
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}
] |
[
{
"content": "A 7-year-old boy was referred by the police from an orphanage with reports of sexual abuse by a 14-year-old boy another inmate of the",
"role": "user"
},
{
"content": " same orphanage. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 26-year-old Saudi patient was first referred to our outpatient department (OPD) at King Fahad Hospital of the University in January 1994 as a case of recurrent molar pregnancy for the third time with persistent trophoblastic disease. She gave a history of three previous histologically proven molar pregnancies since her marriage two years ago, treated in a peripheral hospital. The patient continued to have vaginal bleeding for a month after the procedure. The serum β-human chorionic gonadotropin (β-hCG) was found to be 15,444 IU and a chest X-ray, renal and liver function tests were normal. She underwent a repeat uterine curettage in her base hospital which showed necrotic endometrial tissue. Unfortunately, she continued to have intermittent vaginal bleeding and hence referred to our hospital after 10 days. Her β-hCG on presentation was 4 458 IU and the ultrasound showed endometrial thickening, so she underwent dilatation and curettage. Histopathology reported necrotic decidua only. The patient ",
"role": "user"
},
{
"content": " was given the oral contraceptive pill and followed <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 59-year-old male patient on haemodialysis presented feeling unwell and with fever of 2 days duration.\nThe patient had a complex previous medical history and had been chronically ill for quite some time. He had complications of diabetes in the form of peripheral neuropathy and diabetic retinopathy. Furthermore, he had been diagnosed with CLL in July 2003, for which he had initially received chemotherapy with fludarabine and cyclophosphamide. As of now, he was deemed stable in this regard and had not received any chemotherapy whatsoever for several years. However, on the background of diabetic nephropathy, he had started haemodialysis in 2006. Four weeks prior to the current admission, he had been hospitalized with urinary tract infection and prostatic abscess. Cultures had been negative. He had received a prolonged course of ciprofloxacin and had made an uneventful recovery.\nOn presentation to our unit, he was febrile and appeared acutely unwell, although he was still haemodynamically stable. Clinical examination showed extensive soft tissue swelling with erythema on his left shoulder and a 4-mm central necrotic lesion () as well as enlarged cervical lymph nodes bilaterally. On closer questioning, the patient recalled some minor trauma to the shoulder a few days previously. This minor trauma involved grazing his left shoulder along the door edge. The inju",
"role": "user"
},
{
"content": " ry was so trivial that he had not <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 43-years-old male patient reported to the Department of Oral Medicine and Radiology, Bapuji Dental College and Hospital, Davangere with the chief complaint of swelling in the gums in right upper front teeth region for fifteen days. The growth pattern of the tumor was slow and gradual without any associated symptoms. Patient is a known tobacco chewer and an alcoholic since ten years. Extraoral examination revealed a diffused swelling in the right side of the upper lip extending from the midline to the corner of the upper lip below the ala of the nose and above the upper line of the lip. T",
"role": "user"
},
{
"content": " here was mild obliteration of the nasolabial sulcus. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 27-year-old female patient presented with an indolent but progressive swelling of the right mid femur over the last 2–3 months in our outpatient consultation hour of our university hospital. She reported of a known osteogenisis imperfecta type V, being the only member of her family suffering from it. Clinical phenotype was characterized by short statue, a mild kypho-scoliosis, a short neck and a mild ligamentous hyperlaxity. She did not report of a trauma or any inflammatory disease. Although numerous fractures of the lower extremities occurred over the last decade which were treated conservatively as well as operatively by intramedullary nailing, HPC or extraordinary swelling never developed.\nConventional radiographs of the affected area showed a massive osseous tumor of the right femoral mid-shaft (). Radiographically the lesion was characterized by a massive irregular hypertrophic lamellar ossification with an irregular sunburst pattern as well as the appearance of spiculae, showing potential periosteal signs of malignancy. Laboratory tests only showed an elevated level of alkaline phosphatase of 25",
"role": "user"
},
{
"content": " 7 U/l. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 16-year-old boy presented at the outpatient Department of Ophthalmology with chief complaints of continuous irritation of the right eye along with infrequent watering since 5 months. There was no history of loss of vision. Apparently, the patient also noted a small swelling over the right lower eyelid which was gradually increasing in size th",
"role": "user"
},
{
"content": " ereby causing a cosmetic problem as well. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 54-year-old man with a past medical history significant only for hypertension presented to our clinic with a large soft tissue growth on hislower back which had been present for the past 20 years. Over the past three years it had been rapidly enlarging, nearly doubling in size over that time frame. He had recently re-established medical care after having not seen a physician since childhood. At the time of presentation, he denied any pain or tenderness over the mass and denied any systemic symptoms such as fever, night sweats, and weight loss. The patient had an unremarkable physical exam except for the large soft tissue mass over the lower back, with the maxiumum dimension measured to be 38cm () .\nAfter evaluation by the surgical oncology and radiation oncology services, an abdominal CT scan was obtained and thisdemonstrated a large (35 cm, x 38 cm x 17 cm), heterogeneous soft tissue mass. A differential diagnosis consisting of teratoma versus liposarcoma was established based on the radiologic imaging. Subsequently, several core biopsies of the mass were performed, all of which revealed fat necrosis with calcifications.Surprisingly, given the size and rapid growth of the mass, a diagnosis of benign giant lipoma was made.\nFour weeks after presentation, several surrgical teams performed a six hour operation to remove the 14 kilogram mass. After the patient was widely prepped and draped, the skin overlying the central portion of the tumor was shaved and harvested as multiple split thickess skin grafts (). Subsequently, an incision was made in the s",
"role": "user"
},
{
"content": " kin overlying the tumor in <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 69-year-old man was admitted to a district general hospital with a flare of Crohn's colitis. His symptoms included bloody diarrhoea, with ten to fifteen episodes per day. He had a two-year history of ileocolonic Crohn's disease, and otherwise his past medical history was unremarkable. At ward level, he was alert, orientated, and independent with personal self-care.\nConventional treatment with 5-ASAs and azathioprine had failed to achieve remission, although he had been unable to tolerate doses greater than 100 mg of azathioprine due to nausea. As a result, he had become steroid dependent and had been taking continuous prednisolone for seven months prior to admission, with 20 mg being the lowest dose achieved during that time. Intravenous steroids (100 mg hydrocortisone qds) did not improve symptoms when he was admitted to hospital, and as per the initial outpatient plan discussed with the surgical team, biologic therapy was considered to be the nex",
"role": "user"
},
{
"content": " t step for this gentleman. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 60-year-old male patient was presented to our outpatient clinic with the complaints of swelling and pain in the second finger of his right hand. BD had been diagnosed 33 years earlier. He had experienced swelling in his right knee about 30 years earlier, but he was symptom-free after joint aspiration. Then, 20 years ago, he had a swollen left ankle, which improved spontaneously within 10 days. At that time, he used colchicine for 2 years, but stopped this drug himself due to gastrointestinal adverse effects. At the time of presentation to our clinic, the patient had not used colchici",
"role": "user"
},
{
"content": " ne or other medication for the last 10 years. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 54-year-old male underwent a renal transplantation ",
"role": "user"
},
{
"content": " for end-stage renal disease secondary to diabetic nephropathy <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 70 years old man referred to emergency department of Qaem Hospital, Mashhad, Iran, for rescue percutaneous coronary intervention (PCI) with ongoing severe retrosternal chest pain after thrombolytic therapy after anterior myocardial infarction (MI). He had a history of prolonged smoking and consumption of anti-hypertensive drugs. 12-lead electrocardiogram (ECG) showed anterior MI. The patient underwent echocardiography and initial management of acute MI was immediately initiated. Left ventricle ejection fraction was 30% accompanied with severe aortic insufficiency and hypokinetic anterior myocardium as well as mild mitral valve and tricuspid valve regurgitation (pulmonary artery pressure: 39 mmHg). Coronary artery angiography revealed insignificant plaque in left main artery and cut off in LAD, despite normal left circumflex (LCX) and right coronary arteries. Due to severe aortic valve insufficiency, he was candidate for coronary artery bypass graft (CABG) and aortic valve replacement (AVR).\nBecause of ongoing chest pain, POBA on LAD was performed to reduce pain. POBA was performed on LAD by a 2*15 balloon followed by prolonged dilation with a 3*20 balloon. Post POBA thrombolysis in myocardial infarction (TIMI) 3 was established in the last view.\nAfter POBA on LAD and withdrawing of guiding catheter, a pulsating mass began to grow on patient’s right arm at right brachial artery area. Distal pulses on both upper extremities were symmetrical and there was no sign of distal pallor or cyanosis. Compression along brachial artery began immediately according to possible diagnosis of brachial artery hematoma. The initial diagnosis was brachial artery perforation, so Immediate brachial angiography was performed and no extravasation was seen ().\nThe pulsating mass was not resolved after compression for several times. Therefore, vascular surgeon consultation was performed and the patient was transferred to the coronary care unit. Surprisingly, after a few minutes, the mass disappeared when the patient started to use",
"role": "user"
},
{
"content": " his hand by performing active flexion of the elbow. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 56-year-old male was transferred from a local hospital following a generalized tonic–clonic seizure. Computed tomography (CT) of the brain confirmed the presence of six intracranial needles that appeared to have been inserted into the left frontal lobe through the frontal sinus.\nThe patient has a background history of schizophrenia, and amphetamine and marijuana abuse. The patient des",
"role": "user"
},
{
"content": " cribed a psychotic episode 6 years <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 16-year-old female presented on August 25, 2016 to a tertiary care hospital in Islamabad, Pakistan with the complaints of nausea, vomiting, feverish feeling, fatigue and diarrhea. She was a student and belonged to the rural Punjab province of the country. The patient was clinically diagnosed to have coeliac disease and had presented with recurrent episodes of diarrhea and anemia in the past as well. On her several past visits since September 2015 to this hospital, she was found to ha",
"role": "user"
},
{
"content": " ve low hemoglobin, low albumin, <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 42-year-old man presented with a rapidly proliferating painless growth on the lateral aspect of right thigh over 4 months duration []. He had a 4 × 5 cm irregular, brownish, proliferative growth arising from the skin, free of underlying muscles. There were two right inguinal lymph nodes less than 1cm size. Another ulcerative growth was found over the medial malleolus on the left leg with raised edges at the site of old burns scar.[] Patient had more than 100 nevi all over the body and oral cavity brown-black in color, with irregular borders and variegated appearance [Figures and ]. There was extensive actinic damage of the scalp and facial skin. FAMMMS was clinically suspected as the patient had multiple atypical moles on the skin and mucosa along with two distinct proliferative skin malignancies.\nOtorhinolaryngological examination showed a pigmented naevus of right vocal cord. The punch biopsy of the first growth showed amelanotic melanoma (AM) [] and the four-quadrant biopsy of the left leg ulcer showed squamous cell carcinoma (SCC). Multiple skin biopsies showed features of atypical nevi. Ophthalmic examination, abdominal ultrasonography, and chest X-ray were normal. Contrast-enhanced computed tomography (CT) scan of the abdomen during this admission did not show any pancreatic mass. Magnetic resonance imaging scan of the brain was normal.\nPatient's father had died of carcinoma of lung at the age of 40 years. Patient's sister was examined and found to have actinic damage to the scalp resulting in significant alopecia, but did not have any atypical nevi. Patient was unmarried and had no children.\nThe patient was advised wide local excisi",
"role": "user"
},
{
"content": " on of both the AM and SCC with right inguinal <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 58-year-old Japanese man, who underwent surgery to remove thymoma at the age of 54, was admitted to the emergency room on suspicion of stroke, because he acutely developed speech difficulties. His past medical history was unremarkable except for thymoma that was detected by chance during a health screening. After the thymoma resection, he had been well without recurrence, and received no medical treatment. His family history was also unremarkable. Vital signs were normal except a mild fever (37.8 °C). His general condition was normal ",
"role": "user"
},
{
"content": " (height: 160 cm, weight: 60 kg). <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "Twelve-year-old boy presented with very disruptive symptoms of rhinitis with significant nasal obstruction as well as sneezing, rhinorrhoea and very disturbing nasal and ocular pruritus. These symptoms developed every year during the summer months and were persistent and severe, affecting his ability to sleep and his performance at school. His exam marks were lower in his summer examinations compared to those earlier in the year. He also felt that his nose problems were restricting his sport and social activities during the period when the weather was good; he liked playing outside. He was tested for different airborne allergens and both skin and specific IgE testing showed sensitization to grass pollen confirming grass pollen allergy. The previous years, he had been prescribed loratadine, intranasal mometasone furoate, montelukast and sodium cromoglicate eye drops, which he was taking. Despite good adherence, he continued to have poor disease control.\nGiven his continued symptoms, that were impacting on this quality of life, despite optimal pharmacotherapy, he was started on sublingual immunotherapy to grass pollen. He took the first dose in clinic and continued with the treatment at home. He initially had some local pruritus but ",
"role": "user"
},
{
"content": " this settled after a couple of weeks. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "This case describes a 29-year-old woman who was first di",
"role": "user"
},
{
"content": " agnosed with ameloblastoma as a child at 7 years old. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 52-year-old male patient without a significant medical history was admitted to a local hospital reporting palpitations, lightheadedness, and presyncope symptomatology that firstly occurred one week before his admission. The electrocardiogram (ECG) demonstrated tachycardia–bradycardia syndrome, and the 24-hour ECG Holter monitoring revealed a sinus rhythm, with frequent episodes of paroxistic atrial fibrillation, a prolonged sinus pause of 2.97 seconds following the termination of tachycardia, and then the restoration of a sinus rhythm with severe sinus bradycardia before reaching the baseline heart rate of 55 beats per minute (A).\nConsidering the definite correlation between the symptoms and the electrocardiographic findings, the diagnosis was of sinus node disease, brady–tachy form, with symptomatic intermittent sinus bradycardia, prolonged sinus pauses, and a Class IB indication for cardiac pacing []. The patient was therefore referred to our cardiology clinic for a dual-chamber, permanent pacemaker implantation.\nThe physical examination revealed a 4/6 systolic murmur with a maximum of intensity on the left sternal border. No diastolic murmur was present. The ECG performed in our clinic demonstrated a sinus rhythm, a benign early repolarization pattern, and an increased voltage of the QRS complex, which was interpreted as a normal feature considering the physical constitution of the patient, who was very tall and thin. However, subtle secondary repolarization changes in lead V6 and the inferior leads could suggest an early stage of left ventricle hypertrophy (B). Transthoracic echocardiography showed a subaortic thin membrane located at 9 mm below the aortic valve (A). The subaortic membrane caused moderate subaortic stenosis with a mean gradient of 37.3 mmHg and mild aortic regurgitatio",
"role": "user"
},
{
"content": " n (see ). <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 69-year-old male presented to the emergency room of his local area hospital. The patient had been suffering from recurrent syncopal events for 3 days prior to admission. From his previous medical history, he had undergone pacemaker (Medtronic Sensia SR/single chamber) implantation one year previously due to degenerative complete atrioventricular block. The patient was lost to follow-up for approximately 8 months.\nDuring admission, the patient was haemodynamically stable. The emergency physician performed an initial electrocardiogram that showed pacemaker rhythm (VVI) with a heart rate of 60 bpm (). There was no sign of pacemaker malfunction. The patient was then transferred to the general ward for further evaluation of the cause of syncope. Pacemaker interrogation was not performed at that time as the programming device was not available in that hospital.\nIn the early hours of observation, nothing untoward occurred. Blood work was concluded as normal and no abnormalities were found. However, another syncopal attack took place, followed by cardiac arrest. The patient underwent resuscitation. The ECG at that time showed an episode of ventricular asystole without any sign of a pacemaker spike on ECG strips (). The patient was then transferred to the catheterization laboratory for transvenous temporary pacemaker insertion. During the procedure, the attending physician noticed that the permanent pacemaker lead was in the correct position (right ventricular apex) but there was a noticeable breakage in the lead continuity.\nThe following day, the patient was transferred to our hospital. The pacemaker interrogation revealed high impe",
"role": "user"
},
{
"content": " dance (1. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 63 year old male patient presented with a large 8 × 8 cm ulcerated and suppurating tumour of the scalp (Fig. ). The patient had suffered from an electrical burn at the age of 5 with delayed and incomplete healing of the wound and subsequent baldness in the healed area. The wound had never been completely healed and ulcerated again 8 weeks before admission to the hospital. The patient, a professor of philosophy, wore a turban for decades to hide the chronic wound. Due to personal neglect and the circumstance that he had been living on his own for many years, without any relatives or a partner kept him from seeing a doctor. The disease only received medical attention when he suddenly experienced a complete aphasia during lectures.\nClinically there was a palpable mass adherent to the skull. Nuclear magnetic resonance and computed tomography imaging revealed a tumour with infiltration of the cranium and the brain (Fig. ). Radical resection of the tumour including the cranium, as well as dura mater and the affected parts of the frontal cortex was performed. The dural defect was closed with an autologous fascia lata patch from the right thigh, and as recipient vessels, the superficial temporal artery and vein were dissected. A radial forearm flap with a 10 × 10 cm skin paddle was harvested with an adequately long vascular pedicle. Radial artery and vein were anastomosed end-to-end to the superficial temporal vessels above the zygomatic arch. The donor site was covered with a split thickness skin graft from the thigh (Fig. ). Histology of the specimen revealed a squamous cell carcinoma and free resectional margins. Postoperative heal",
"role": "user"
},
{
"content": " ing was uneventful and the patient <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 10-year-old boy visited the Department of Pedodontics with the complaint of being unable to chew on his right side. Upon examination, the lower arch contained the following teeth: 36, 35, 34, 73, 32, 31, 41, 42, 83, and 46 (). The upper arch contained teeth consistent with the intertransitional period, except that 14 had erupted (). Upon history taking, it was gathered that 84 and 85 had been extracted a year ago due to extensive caries and severe pain. An orthopantomograph (OPG) revealed half root completion of the unerupted 44 and 45 (). It was decided to construct a LHLD (functional lingual arch with hinge-type lockable dentulous component) in order to maintain the edentulous span until the eruption of 44 and 45, and to relieve the child of his chewing disab",
"role": "user"
},
{
"content": " ility. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "History and examination\nA 41-year-old Hispanic male originally presented to the neurology service for evaluation of low back pain with a burning sensation in bilateral lower extremities. During the exam, it was noted he had brisk reflexes. Therefore, the neurologist recommended a cervical MRI which ultimately demonstrated severe cervical stenosis at C1 with severe cord compression (Figure ). The patient was referred to the neurosurgery clinic where he endorsed inability to carry things for long periods of time due to hand weakness that had been worsening over six months. Moreover, he stated that he was unable to perform his job as a butcher due to inability to hold his knife. Upon reviewing the patient's MRI and based on clinical exam of hyperreflexia throughout, bilateral clonus, bilateral Hoffman's, and 4+/5 strength in bilateral deltoids and grip, it was quickly determined that the cervical cord decompression was a priority, and he was scheduled for a C1 laminectomy with intraoperative neuromonitoring.\nOperation\nPrior to positioning as well as intraoperatively, somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) were present, equal, and reproducible in all four extremities. Anesthesia was asked to keep mean arterial pressure (MAP) greater than 85 mmHg throughout the entire surgery. After removal of the posterior C1 arch, all SSEPs and MEPs were still present and reproducible. Shortly thereafter, the neuromonitoring technician was manipulating the needles in the scalp and when asked the reasoning, we were informed that SSEPs were gone from the hands, followed by all extremities, followed by loss of MEPs in the upper extremities. At that time, we stopped all surgical manipulation, and the MAP was confirmed to be greater than 85 mmHg that we requested at the beginning of the case",
"role": "user"
},
{
"content": " . <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 17 years old female, presented with complaints of headache and episodes of vomiting for 16 months duration. She also had amenorrhea, excessive weight gain, and memory lapses for one year. She was initially eva",
"role": "user"
},
{
"content": " luated at another hospital and <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 30-year old African American woman presented to the emergency department complaining of shortness of breath on exertion and chest pain with deep inspiration. Otherwise, the patient stated she was well. There was no indication of recent infections.\nHer physical examination did not yield ",
"role": "user"
},
{
"content": " any abnormalities or concerns. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "Patient: a 55-year-old Japanese female.\nNone of the factors contributing to lateral compartment knee disease, such as obesity, complications, or psychiatric disorders, were present in the patient. During hyaluronic acid (HA) treatment, although we prescribed strength training to the patient, she did not perform it frequently enough because of severe pain. As the knee pain",
"role": "user"
},
{
"content": " was caused by tripping while playing <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 32-year-old multiparous woman was admitted at 37 2/7 weeks for induction of labor for abnormal antenatal testing. She had a history of a prior cesarean delivery for arrest of active labor at 7 cm and after extensive counseling chose to undergo a TOLAC. The initial cervical exam was 2 cm dilation and 50% effacement. Her labor was induced with oxytocin and amniotomy was performed at 5 cm dilation with clear fluid noted. She progressed from 2 cm to 5 cm over the course of 10 hours; interval time to progression to 6 cm was 3.5 hours. The patient then began to have a moderate amount of vaginal bleeding with associated minimal fetal heart rate variability and variable decelerations that did not improve with intrauterine resuscitation. She was taken to the operating room for repeat cesarean delivery due to concern for a uterine rupture and/or a placental abruption. Upon entry into the abdomen, there was no uterine rupture or dehiscence, nor was there evidence of a significant placental abruption. She delivered a male infant with a ",
"role": "user"
},
{
"content": " weight of 2659 g and Apgar <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A previously healthy 54-year-old Caucasian man presented to the emergency department of our internal medicine ward with a medical history of aggravation of general ",
"role": "user"
},
{
"content": " health related to dizziness, weight gain, and two syncopal attacks. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 65-year-old male positive for hepatitis C virus antibody had been treated for HCCs in the liver segments 5, 6, 7, 8 in our hospital since October 2014. The patient was initially treated for the ruptured HCC in the segment 5 with TACE, while subsequent examinations detected other HCCs in segments 6, 7 and 8 which were similarly treated by 2nd line TACE, following the Japanese HCC therapeutic guidelines. After the treatment, the tumors in segments 6 and 7 were well controlled, while the pre-ruptured tumor in segment 5 and the lesion in segment 8 still remained viable. Hence, a 3rd line TACE was performed after 6 months: while the segment 8 tumor were well embolized after the treatment, the segment 5 tumor c",
"role": "user"
},
{
"content": " ould not be embolized completely. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 65-year-old male patient came to the hospital with multiple traumatic brain injuries caused by a motorcycle accident. He had a history of diabetes and asthma, for which he had been pharmacologically treated for several years. He also had a history of open surgery to treat peritonitis 3 years before. Upon arrival at the hospital, he was in a lethargic state (Glasgow coma scale; E3V5M5), with a loss of direct and indirect light reflexes due to damage to the right optic nerve. Skull X-ray and cranial computed tomography (CT) showed comminuted fractures of the skull and multiple areas around the skull base, a Le Fort type II fracture of the facial bones, multiple comminuted fractures of the nose and around the orbit, and a small amount of pneumocephalus in the anterior recess (). Plastic surgeons decided to delay operating on the facial fractures because of severe edema of the face and orbit, and the patient was treated conservatively at the bedside. On day 8 following the trauma, the patient complained of severe headache and nausea, and CT performed on day 8 revealed a large tension pneumocephalus with a tented configuration and noticeably enlarged shadows of air compressing both sides of the frontal lobe (). As an emergency treatment, a rupture of the dura mater in the area of the right anterior cranial fossa was sutured using a subfrontal approach, and fixation surgery was performed on fragments of the comminuted fractures. Four days later, open reduction and fixation surgery were performed on the multiple facial fractures in the department of plastic surgery. On cranial CT pe",
"role": "user"
},
{
"content": " rformed 2 weeks postsurgery, pneumocephalus was no longer observed (). <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "We report the case of a seventy four year old man who presented to the Emergency Department complaining of back pain of two months duration. This was a dull mid- thoracic back pain with radiation to the chest and upper abdomen. It was",
"role": "user"
},
{
"content": " initially intermittent associated with exertion, but <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 23-year-old man (weight 65 kg, height 175 cm, and BSA 1.8 m2) with a diagnosis of primitive right atrial enlargement from foetal age was referred to our Centre for cardiological evaluation. Cardiac examination showed increased heart size on percussion and a grade II/VI Levine systolic murmur. No significant pathological findings were found on pulmonary examination. Electrocardiography showed a regular sinus rhythm with a rate of approximately 60 beats/min associated with an abnormal morphology and duration of P wave (enlargement of P wave with duration of 130 msec), together with a low amplitude of QRS complexes in the limb leads. All routine laboratory studies were within normal limits. Chest radiography showed an abnormal cardiac silhouette with increased convexity in the lower half of the right cardiac border and cardiomegaly ().\nTransthoracic two-dimensional echocardiography demonstrated a huge right atrium of about 6.2 cm and a volume of 230 ml/m2, with a thick smoke pattern and mild tricuspid regurgitation. The pulmonary arterial pressure was normal (). The tricuspid valve was norma",
"role": "user"
},
{
"content": " l without significant annular dilation. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 69-yea",
"role": "user"
},
{
"content": " r-old Filipino man with history significant for <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 50-year-old man was referred to the breast unit presenting with a month's history of a suspicious lump in his left breast. He had no family history of cancer. From his medical history, the only remarkable finding was hepatitis B 30 years previously and genital herpes for which he was taking Acyclovir. He had a history of smoking (30 packs per year).\nClinic",
"role": "user"
},
{
"content": " ally, he had a lump centrally in the <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "Our patient is a 5-year-old female who was referred for evaluat",
"role": "user"
},
{
"content": " ion and management of recurrent episodes of <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 24-year-old-male presented to the emergency department (ED) via ambulance for symptomatic hypotension he experienced while running. Approximately ten minutes",
"role": "user"
},
{
"content": " into his run, he began <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 32-year-old woman presented with concerns of intermittent right upper abdominal pain for one year. Her liver function tests were within normal limits. Ultrasonography (USG) revealed cholelithiasis along with choledocholithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) revealed two small filling defects, and we extracted the stone via stent placement in the common bile duct (CBD). She underwent open cholecystectomy one month following ERCP. Intraoperatively, we noted the gall bladder (GB) was contracted and filled with multiple calculi, the CBD was dilated, and the hepatoduodenal ligament was frozen. Intraoperatively there was no suspicion of any bowel injury. An abdominal drain was placed in the right subhepatic region. She was discharged on postoperative day (POD) three with a drain in situ due to persistent serosanguinous discharge. The abdominal drain was removed on POD eight as output was decreased. A GB biopsy showed features of chronic cholecystitis.\nFollowing",
"role": "user"
},
{
"content": " drain removal the next day on <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 21-year-old female presented to the Case Western Reserve University School of Dental Medicine Clinic in Cleveland, Ohio. Her chief complaint was a slowly growing painless swelling involving the right side of the mandible that had started one year previously. Her past medical history revealed no previous surgeries or diseases. Her vital signs were recorded as 120/80 mmHg blood pressure, a pulse of 103 beats per minute (bpm), 15 respirations per minute, height - 5.1 ft, weight - 165 lb, and a calculated body mass index (BMI) of 23.71. No other medical conditions were identified, and the patient did not report taking any medications. Clinical examination revealed an intraoral swelling involving the posterior part of the body of the mandible and extending to the ramus on the right side. On palpation, the lesion was hard in consistency, except for select areas which exhibited a softer texture.\nThe patient was referred to a private dental imaging center for a CBCT scan to evaluate the extent of the lesion. A board-certified oral and maxillofacial radiologist performed the radiographic interpretation of the CBCT scan. The scan revealed a well-defined radiolucent lesion ranging from the interdental bone in between the second and third right molars and extending to the ramus of the mandible posteriorly in the anteroposterior direction. The lesion extended from the alveolar crest to the inferior border of the mandible in the superior-inferior direction (Figure ).\nOsteolytic changes of the alveolar crest margin distal to the third molar were noted and displaced the roots of the third molar more distally. The sagittal cut showed that the lesion had a multilocular appearance with an incomplete internal septal structure, demonstrating wispy-like septations. The inferior border of the mandible showed some resorption with undulating borders (Figure ). The lesion showed expansion of the alveolar crest. In axial cuts, the lesion involv",
"role": "user"
},
{
"content": " ed the ramus of the mandible, and expansion and thinning <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 50-year-old male was admitted to the hospital with ongoing chest pain. Eleven years ago, he underwent implantation of a mechanical aortic valve prosthesis due to degenerated bicuspid valve with no",
"role": "user"
},
{
"content": " rmal coronaries on preoperative angiography. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "An 83-year-old woman with a history of basal cell carcinoma and squamous cell carcinoma presented to our clinic for evaluation of a right midback mass. She initially presented to her dermatologist with what appeared to be an inflamed sebaceous cyst, but after a failed trial of Keflex, a punch biopsy performed at an outside institution revealed dermal involvement by invasive, poorly differentiated carcinoma with epidermoid features. By immunohistochemistry, the tumor cells expressed high-molecular weight keratin, BerEP4, and EMA but were negative for P63, GCDFP15, estrogen receptor, progesterone receptor, TTF-1, CEA, cytokeratin 7, and cytokeratin 20. At this point, the etiology of her mass was unclear; however, it should be noted that the patient was 6 weeks post-op",
"role": "user"
},
{
"content": " from a laparoscopic-assisted left colectomy at <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "The patient, an ethnically Japanese 2-year-old boy, was referred to our hospital with dysstasia and transaminitis. In Fig. , representative clinical manifestation and laboratory data are shown. The boy was well since birth until the onset of illness. On the first day, he developed a fever and was treated with acetaminophen suppositories. On the second day after onset of illness, his family took him to a nearby clinic because of the persistent fever, along with diarrhea and vomiting. Additionally, the child was unable to stand. A rapid diagnostic test for influenza A and B viral antigens yielded negative results. Although the fever subsided on the third day, the child was still unable to stand and was taken to the clinic again (Fig. ). Physical examination showed muscle weakness in the lower extremities. Blood examination revealed high levels of transaminases, indicative of rhabdomyolysis. Thus, the child was admitted to our hospital.\nOn admission (11 January 2012), there was no fever, and the child was awake and alert. Vital signs were normal, except for slight tachycardia. Examination of the chest an",
"role": "user"
},
{
"content": " d abdomen revealed no abnormalities. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 28-year-old healthy left-handed man was transferred to our emergency room 6 h after having his left hand crushed once in a box flattening machine at a winery warehouse. He reported increasing severe left hand pain, numbness, and dif",
"role": "user"
},
{
"content": " ficulty moving his fingers and wrist. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 78-year-old Japanese male presented to the emergency department of our hospital with low back pain on exertion for 1 week. The pain was described as dull and gradually worsens. Although the location was near the thoracolumbar spine, he denied radiation of the pain to any parts of the body. Severity of pain using a numerical rating scale was 10/10 at the day of admission. The character and intensity of the pain were not affected by changes in physical movement or by rest. He denied any other symptoms such as fever, nausea, dysuria, hematuria, abdominal pain, and leg numbness during his clinical course.\nHe had a past medical history of rectal cancer with liv",
"role": "user"
},
{
"content": " er metastasis and had undergone surgery and chemotherapy. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 65-year-old man arrived at the emergency room because of acute consciousness disturbance. TC of the brain showed a hemorrhage in the mesencephalic region. His conditions were very critical (GCS = 3), even if the brea",
"role": "user"
},
{
"content": " thing function was normal. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 54-year-old woman reported to the dental office with pain and swelling in the right mandibular posterior region. The medical history was non-contributory. She had no history of traumatic injury or orthodontic treatment. Clinical examination showed small intraoral swelling with relation to 45. The tooth was slightly tender to percussion and served as an abutment to a long span bridge extending upto 48. The probing depths were within normal limits.\nIntraoral periapical radiographic examination revealed",
"role": "user"
},
{
"content": " a well-circumscribed, fairly round radiolucency in the <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "Systemically healthy 24-year-old male patient came to Department of Periodontics, with the complaint of unaesthetic appearance of upper central teeth because of forwardly placed maxillary left central incisor since 6 months. Patient gave history of extraction of supernumerary tooth, which was placed palatal to 11 and 21, 3 months back. 21 had gradually come to the present position over 6 months []. Patient was also complaining about functional problems of the upper central teeth because of loss of biting ability due to forwardly placed and mobile tooth. During the clinical examination, approximately 6 mm of periodontal pocket were observed with 21. Radiographic examination was revealed moderate alveolar bone resorption reaching to the middle third of the tooth []. Mobility of the tooth was Grade II.\nPatient demanded not to loose any teeth because of psychological reasons during the treatment plan phase. Considering patient's demands and the clinical situation, the treatment plan of upper anterior teeth (21) decided as Phase I periodontal therapy and intentional replantation and relocation of maxillary left central incisor followed by periodontal splint. Oral hygiene motivation, scaling and root were as the initial periodontal therapy. At the 4th week after the initial therapy, a considerable improvement in o",
"role": "user"
},
{
"content": " ral hygiene and gingival health and <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 15-month-old male presented to the Emergency Department (ED) with sudden onset of right arm and leg weakness beginning 3 hours prior to admission. His clinical history included a viral illness 5 days prior to admission, with malaise, fever, vomiting, and diarrhea. Early in the course of that illness he was seen by a pediatrician who noted mild dehydration, and suggested oral rehydration and antipyretics. He was otherwise healthy, with up-to-date immunizations.\nOn arrival to the ED physical exam revealed flaccidity in right upper and lower extremities. X-rays of right upper extremity obtained to rule out trauma were negative. Lab results showed microcytic anemia with hemoglobin of 6 g/dL, and thrombocytosis, with a platelet count of 512,000. The remaining labs were normal. Computed tomography (CT) of the head without contrast showed hypodensity of the left thalamus (). In addition, high attenuation was noted throughout the bilateral deep venous system, compatible with acute DCVT ().\nAnticoagulation therapy and IV hydration were initiated immediately after radiologic findings were discussed with the ED physician. The patient was transferred to the Intensive Care Unit of our tertiary pediatric hospital. Magnetic resonance imaging (MRI) of the brain demonstrated rest",
"role": "user"
},
{
"content": " ricted diffusion in the central <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "An abnormal shadow with anterior mediastinal calcification and an elevated left hemidiaphragm was incidentally observed in a 57-year-old man who underwent chest radiography during a periodic health examin",
"role": "user"
},
{
"content": " ation (Fig ). <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "Term 37 and 1 7 weeks appropriate for gestational age male neonate . Exaggerated physiologic hyperbilirubinemia responsive to phototherapy .",
"role": "user"
},
{
"content": " ', 'Nicole Monica MD 48-041 Dictated By Michelle <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "We report the case of a 59-year-old man with hypertension and dyslipidemia, both of which were being treated by his primary physician. The patient suffered a traumatic lumbar fracture in 2013 owing to a fall and underwent surgery. Computed tomography (CT) scans performed at the time were focused on the lumbar spine, so other organs were barely included in the image range and no contrast medium was used. However, when carefully observed retrospectively, the CT scan showed a partial inward deviation of the intimal calcification of the abdominal aorta, suggesting a localized dissection of the abdominal aorta (). However, there was no mention of localized aortic dissection, because the dissection was fairly localized and did not show any abnormal findings, such as aneurysm formation. In addition, the adventitia causing the aortic dissection was also calcified. The findings suggested a chronic aortic dissection that occurred even before the trauma, rather than an acute aortic dissection that occurred at the time of the trauma.\nIn March 2020, the patient was admitted to the emergency department of a nearby general hospital for vomiting. He had no abdominal pain and was subsequently diagnosed with acute gastroenteritis and prescribed oral medication. On physical examination, palpation of the abdomen revealed a pulsating mass, and the patient subsequently consulted his family doctor. After abdominal ultrasound examination, the patient's doctor diagnosed him with an AAA. He subsequently referred the patient to another hospital for a contrast CT scan and a full workup of the AAA. After the enh",
"role": "user"
},
{
"content": " anced CT scan, the patient was referred to <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "We present a case of a 74-year-old man smoker patient with NSCLC with bone metastases (T2NXM1) and HCC (BCLC stage C). The patient had a related liver cirrhosis metabolic syndrome, good liver",
"role": "user"
},
{
"content": " function (Child Pugh A5), and reported <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "This is the case of a 53-year-old Japanese male with schizophrenia who had been hospitalized at Takano Hospital from the age of 29. Haloperidol was continuously prescribed, and he was mentally stable before the disaster. His parents died during his hospitalization, and he did not have any social or financial support from other family members, which was one reason for his long-term hospitalization. This type of long-term hospitalization of psychiatric patients is relatively common in Japan []. His right eyesight and hearing were impaired. He had chronic constipation and took purgative medicines, yet no other abnormalities were noted in terms of his physical condition. Although he maintained positive relationships with the hospital staff, few people regularly visited him, and he had scarce contact with the outside world.\nFrom March 11, 2011, the day of the earthquake and tsunami, to March 19, 2011, the staff at Takano Hospital provided consistent care to the patient, and his mental and physical condition did not significantly deteriorate despite the chaotic postdisaster situation. On March 19, 2011, the number of staff who remained at the hospital d",
"role": "user"
},
{
"content": " ropped to 13, compared to the predisaster baseline of 88. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 15-year-old female patient (bodyweight 50 kg, height 160 cm) presented with syncope. Severe arterial hypertension was diagnosed (178/147 mmHg left arm, 102/83 mmHg left leg). She reported previous episodes of exercise independent headaches and nose bleeds. Auscultation revealed no cardiac murmurs, but an accentuated second heart sound and reduced pulses in the lower limbs. There were no clinical signs to suggest Alagille or William’s syndrome or clinical evidence of neurofibromatosis. Blood tests showed normal inflammatory markers and normal creatinine. The urine dip showed no markers for blood or protein. No regular medication was taken at the time she presented. The electrocardiogram showed normal sinus rhythm, no significant signs of left ventricular (LV) hypertrophy or abnormal repolarization. Echocardiography detected a severe concentric LV hypertrophy (14 mm diastolic septal diameter, 15 mm diastolic diameter of the LV posterior wall) and a long hypoplastic segment in the abdominal aorta with massive arterial collateralization. Cardiac catheterization confirmed the diagnosis of a midaortic syndrome with a minimum diameter of <1.5 mm and a gradient of 50 mmHg between the aortic arch and the femoral arteries (Figure ). The narrow part began directly under the diaphragm above the truncus coeliacus and continued down to the bifurcation of the arteriae iliacae including the renal arteries, with reversed flow in the caudal aorta up to the renal arteries. Because of the extraordinary length of the hypoplastic segment of 23 cm, we decided for a stepwise interventional therapy with a paclitaxel covered balloon. No additional computed tomography scan or magnetic resonance imaging (MRI) was performed. Consultation with our surgeon, supported the interventional approach.",
"role": "user"
},
{
"content": " The proposed procedure was reviewed and approved by our institutional <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "The patient was a 55-year-old male, employed as a manual laborer in Indian Railways. Patient presented in emergency with severe abdominal pain, multiple episodes of vomiting, abdominal distension, and obstipation. He had a history of recurrent attacks of colicky abdominal pain, nausea, and vomiting over the last 2 years. There was a history of hospitalization for occasional episodes of severe abdominal pain and distension and obstipation over this period. The frequency of these attacks had been progressively increasing over the last 2 years with the patient requiring weekly admission for the preceding two months before coming to our centre. There was history of loss of weight and appetite. There was no associated history of fever. There was no contributory past or family history. He was a chronic smoker of 80 packet years and a social alcoholic. He was investigated by CT scan of the abdomen and Thorax and MRI of the abdomen during his previous admissions and was diagnosed as a case of hiatus hernia with retroperitoneal fibrosis/diffuse lymphoproliferative disorder. CT chest showed nodularity indicative of infective pathology. However, these investigations were not available with the patient at the time of admission to our hospital. He was normotensive and afebrile but was having tachycardia and tachypnoea (pulse: 108/minute and respiratory rate: 22/minute). His nutritional status ap",
"role": "user"
},
{
"content": " peared adequate. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 38-year-old Caucasian female reported to the Graduate Periodontics Clinic at the College of Dentistry, The Ohio State University, for a single tooth extraction and implant therapy. A nonrestorable maxillary right central incisor with external root resorption () was observed at the initial examination and was confirmed by a periapical film. The patient reported a history of trauma around the upper anterior teeth resulting in endodontic treatment of teeth 12, 11, and 21. She reported no significant medical history except an allergy to penicillin. She had no history of smoking and was classified as American Society of Anesthesiologists (ASA) Physical Status Classification System I. A comprehensive periodontal exam revealed no probing depths greater than 3 mm, and the embrasure spaces between the maxillary incisors were completely filled with interdental papilla. Neither tooth mobility nor percussion/palpation pain was detected in teeth 12 to 22. Radiographic examination illustrated external root resorption on the distal aspect of",
"role": "user"
},
{
"content": " tooth 11 at the CEJ level with no apical radiolucency. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 60-year-old man with history of type II diabetes mellitus, hypertension, ischemic heart disease, clear cell renal carcinoma (RCC), and recent low grade mucinous neoplasm of the appendix was referred from the urology clinic for evaluation of a scattered subcentimeter intraparenchymal pulmonary nodules found incidentally on follow up for his RCC. A bronchoscopy was performed by another service which revealed an incidental finding of a small posterior upper tracheal lesion. The mass was a less than two centimeter, mobile, irregular vascular tumor protruding from the posterior wall of the trachea and was three centimeters distal to the vocal cords causing partial obstruction. The lesion was excised using endotracheal laser resection. The histology showed primary tracheal schwannoma with positive resection margins. The intraparenchymal nodules were all less than 5 mm and follow up surveillance with low dose computer tomography was recommended. In November 2016 the patient developed a dry cough with occasional wheezes and his follow-up CT scan showed his tracheal tumor had recurred with extratracheal extension (Fig ) and one of the intraparenchymal lung nodules had increased in size into 8 mm. Although the CT characteristics were suggestive of intrapa",
"role": "user"
},
{
"content": " renchymal granuloma, an integrated positron emission tomography <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "In September 2004, a 24-year-old male presented with progressive dyspnea on exertion, paroxysmal atrial fibrillation, malaise, and peripheral eosinophilia. Initial evaluation showed a left atrial mass and a separate mass adherent to the mitral valve for which the patient underwent surgical resection and mechanical mitral valve replacement. The diagnosis of noninfectious hypereosinophilic granulomatous disease was made by histopathologic evaluation. The patient underwent treatment with imatinib mesylate and a 5-month steroid course, which eventually led to complete resolution of eosinophilia, residual masses, and symptoms.\nIn December of 2009, the patient presented to an outside facility with fevers, night sweats, and weight loss and was diagnosed with subacute mechanical valve endocarditis from Streptococcus viridians. TTE noted multiple large vegetations at the four and five o'clock positions of the mechanical valve. The patient underwent a second mitral valve replacement using a 29 mm St. Jude mechanical valve, with a cross-clamp time of 85 minutes and total bypass time of 132 minutes. Intra-operative TEE was performed without mention of aortic valve injury or regurgitation. Pathology r",
"role": "user"
},
{
"content": " eview of the prosthetic valve vegetations showed <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 32-year-old man with a diagnosis of right comminuted mandibular fracture, right comminuted zygomaticomaxillary complex fracture, right mandibular dentoalveolar fracture, and avulsive injuries of soft tissue and skin at his mandible due to gunshot after 18 days was hospitalized, and his injury was in category of penetrative and avulsive wound (Figure ). Right eye had become no light perception (NLP). Through his first surgery, it was decided to treat the fracture of right zygomaticomaxillary complex. Because of avulsive injuries at the mandible, we could not treat the mandible at the same time. After general anesthesia, hemicoronal incision done on the right side, to access the lateral orbital wall, body of zygoma and zygomatic arch. Via a subciliary incision, we had access to infra. Orbital rim and orbital floor and the segments have been reduced and fixed with two four-hole miniplates. Moreover, Medpor prosthesis was placed on the eye floor to reconstruct the defect. To the zygomatic buttress which has been reduced and through vestibular approach we had an access, and fractures fixed with two miniplates, arch bar and IMF has been used for temporary treatment of mandible fracture. Canfield's dressing with honey was used for avulsive soft tissue to regeneration.\nEight months after the first surgery, the second surgery was performed to remove the bullets from the maxillofacial area and reconstruct the mandible. A total sum of nine bullets were extracted from the maxillofacial area with the aid of navigation (Figure ). Then, the arch bars in two jaws were applied; after osteotomy of fracture segments, the teeth were manipulated in appropriate occlusion, and the fragments were fixed with a reconstruction plate and four miniplates. One fragment was fixed with a lag screw. Hence, the mandibular was fixed properly. Thereafter, the patient had the problem of bulky soft tissue in malar and buccal areas due to fibrosis after repa",
"role": "user"
},
{
"content": " ir <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 55-year-old man had a history of alcoholic chronic pancreatitis with intermittent acute exacerbations over the last 6 years. On admission, he described recurrent mild-to-moderate dyspnea after exercise and problems in swallowing solid food. He had lost 5 kg in weight during the last 2 months as a result. Clinical examination was inconclusive; laboratory investigations showed no sign of acute pancreatitis exacerbation. Serum amylase and lipase were within the normal range. On chest X-ray, a semitransparent intrathoracic mass adjacent to the heart as wel",
"role": "user"
},
{
"content": " l as small bilateral pleural effusions were noted (Figure ). <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "Our patient is a 38-year-old man with no significant medical history who initially presented to the outpatient clinic with a 1-month history of axial neck pain and right lateral thoracic pain. The pain was localized to the right 11th intercostal space and was exacerbated by inspiration. He reported no trauma or prior inciting event. On physical examination, he had tenderness to palpation about his posterior neck. Motor and sensory exams were within normal limits with no obvious neurologic deficit. Initial plain AP and lateral radiographs of the cervical spine were normal (Figure ). The patient was initially treated conservatively with NSAIDs and physical therapy. However, 6 weeks later, the patient returned without symptomatic improvement and new onset right upper extremity radiculopathy.\nMRI of the cervical spine was obtained and demonstrated a nongeographic, destructive lesion in the posterior elements of the cervical spine arising from the spinous process of C7 and evidence of spinal cord compression (Figure ). CT scan of the cervical spine demonstrated erosive changes to the C7 spinous process (Figure ). A malignancy workup was performed, and an oncology consult was obtained. Chest/abdomen/pelvis CT scan revealed metastatic disease of the right 11th rib; however, no primary mass was identified. Bone scan showed increased uptake in the right 11th rib, but no other evidence of metastatic bone disease. No primary malignancy was identified on the initial screening. Given the nature of the patient's symptoms and MRI findings, the patient was indicated for surgical intervention for primary resection of the tumor.\nA C6–T1 laminectomy was p",
"role": "user"
},
{
"content": " erformed to gain access to the mass. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 76-year-old male patient diagnosed ambulant with acute ruptured aortic type B dissection was referred to our ICU. He presented with severe tearing pain that migrated from his back and then to his abdomen. He had a history of hypertension, diabetes and hyperlipidemia. Physical examination upon arrival revealed blood pressure of 82/55 mmHg. The patient complained distress and vomiting. Three dimensional reconstruction of the CT angiography showed a dissecting and acute ruptured aneurysm from 1 cm beyond the left subclavian artery with a diameter reaching 4 cm at the largest part. There was also distinctive left side hematothorax (Figure ). Fortunately, all abdominal arteries were feeded by the true lumen with no signs of abdominal malperfusion. Laboratory examination showed highly increased lactate level while haemoglobin was decreased. Based on the severe hemorrhagic shock, the patient was immediately transferred to our hybrid OR. Under general anaesthesia the patient needed high dose inotropic support and showed poor oxygenation despite high pressure ventilation. Our interventional team, consisting of two angiologists and one heart surgeon, decided to release the left pleura due to a 4cm left side mini thoracothomy in the 4th intercostal space and overall delivered three litre fluid hematoma.\nSimultaneously the left femoral artery was surgically accessed and a transversal arteriotomy was performed. A 5F sheath was inserted percutaneously through the right brachial artery, through which a 5F pigtail catheter was dire",
"role": "user"
},
{
"content": " cted for angiographic monitoring of the endovascular graft position. <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 26-year-old male presented with complaints of the sudden occurrence of slurred speech, weakness on the right half of the face, right up",
"role": "user"
},
{
"content": " per limb with subsequent involvement of the right lower <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 68-year-old woman was admitted to a private dental clinic in October 2009, complaining about cold tooth sensation in the region of left mandibular second premolar. Review of the patient's medical history revealed that since 2003, she had been taking 2.5 mg of methotrexate six times a week and 70 mg of Fosamax® (alendronate sodium) once a week for the treatment of rheumatoid arthritis. Besides, she also reported steroids use during twenty years. The patient had no history of radiotherapy, infectious process or trauma in the maxillofacial region but did have a history of smoking.\nDuring clinical examination a detachment of the marginal gingival (Figure ) associated with an increased probing depth value at the region of left mandibular second premolar (Figure ",
"role": "user"
},
{
"content": " ) was observed and was associated with a <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 73-year-old woman complained of left knee pain without a history of trauma or any systemic disorder that might have caused joint pain. Physical examination revealed tenderness in the medial knee joint. In addition, plain radiographs revealed no degenerative changes, suggesting Kellgren-Lawrence grade 1 (). The femorotibial angle was 173° on standing. Laboratory findings were within normal limits. Areal BMD measurement was performed at the proximal femur using dual ener",
"role": "user"
},
{
"content": " gy X-ray absorptiometry (DXA) (Hologic QDR Discovery <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 25-year-old female patient was admitted to the emergency service with multiple traumas following a motor vehicle accident. The patient was reported to have been riding in the back seat of the vehicle without the safety belt fastened when the vehicle rolled down an embankment. The patient was conscious but agitated. Bilateral globes were completely out of their sockets (fig. ). During examination, the right pupil was dilated and bilaterally did not react to light. The patient had no light perception bilaterally. The right globe was intact in appearance but hypotonic. The anterior segment of the left globe was normal; however, the right fundus could not be visualized. The left eye fundus examination revealed patches of hemorrhage around the optic disk. The patient had deep cuts of 4 cm towards the right lateral section of the upper lip and 5 cm on the lower jaw.\nA cranial and orbital tomography revealed multiple comminuted fractures of the nasal bones, ethmoidal bone, both zygomatic bones, hard palate, right maxillary alveolar bone, and right pterygoid process. The fracture arch passed through the whole walls of both orbits except for the orbital roofs, all walls of the right maxillary sinus and all walls of the left maxillary sinus except for the anterior wall were classified as Le Fort II fracture. There were also fractures of the bony septum and the sphenoid sinus. All paranasal sinuses were filled with blood. There was a displaced fracture of the right mandib",
"role": "user"
},
{
"content": " ular ramus and angulation of the condyle to the <|endoftext|>",
"role": "assistant"
}
] |
[
{
"content": "A 63-year-old Chinese male with end-stage renal failure secondary to reflux nephropathy had been undergoing continuous ambu",
"role": "user"
},
{
"content": " latory PD for the past two years. <|endoftext|>",
"role": "assistant"
}
] |
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