Split (2)

train · 166k rows

messages listlengths 2 2
[ { "content": "A 40-year-old man with a known diagnosis of Immunoglobulin D (IgD) lambda multiple myeloma presented with relapsed multiple myeloma (MM). He first presented in September 2007 with the chief complaint of cough and left sided abdominal pain. Physical examination was significant for splenomegaly. His labs were significan", "role": "user" }, { "content": " t for pancytopenia. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 40-year-old female was admitted to the urology department on October 28, 2020 with symptoms of left-sided renal colic. In the interview, the patient denied suffering from chronic diseases or having undergone any surgeries in the past. She also denied smoking and drinking alcohol. The patient initially consented for ureteroscopy (URS) treatment of the left kidney and a DJ catheter was inserted. No complications occurred. However, due to persistent discomfort, a computed tomography (CT) scan of the abdominal cavity was ordered. The CT examination revealed a heterogeneous, poorly demarcated lesion with a clear fat component within the left kidney, with a maximum size of about 97 mm (). The image of the lesion enforced the diagnosis of angiomyolipoma (AML) with sec", "role": "user" }, { "content": " ondary haemorrhagic changes. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 51-year-old female was brought to the hospital late in the evening with a history of loss of strength in the right side of the body for ½ h. The patient was roaming inside her house and suddenly knocked off her feet. She complained ", "role": "user" }, { "content": " of loss of strength in the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A nine-year old boy was admitted to our referral hospital in August 2013 with a history of trauma caused by a fall two days before admission. He had chest pain, and mild respiratory distress and four years with non productive cough. He was sent to our center due to suspicious diagnosis of ruptured giant pulmonary hydatid cysts confirmed by 5 ml hydatid fluid thoracentesis. Chest roentgenogram, demonstrated a mass density of right hemithorax supposed to be massive pleural effusion with mediastinal shifting to the left (Fig. ). On admission, the patient status included the mild respiratory distress (i.e., RR=29, PR=80, T=37. 5), and normal vital signs on physical examinations. Respiratory sounds were not audible over the right side lung. Serologic hemagglutination test (ELISA) for Echinococcosis was also positive. Computed tomography (CT) scan of the chest confirmed the right side pulmonary giant mediastinal cyst with mediastinal shift to the left and an absent shadow of collapsed right lung (Fig. ). He was scheduled for perfoming the thoracotomy. After right-thoracotomy, a giant hydatid cyst with dimensions of 302220cm was found extending from the right diaphragm toward the apex of the lung. There was not any pneumothorax, or pleural effusion at the time of operation owing to severe adhesions of the right pulmonary hydatid cyst to the extensive surface of the chest wall. After lyses of the adhesions, the chest cavity, all around the cyst was covered with spongy hypertonic normal saline. Then, the cyst was removed without contamination, the pericyst was opened and the laminated membrane was extracted from the right lower lobe (RLL). No pulmonary parenchyma remained in the RLL, and right lower lobectomy was successfully performed. The remaining lobes of the lung were expande", "role": "user" }, { "content": " d completely. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "In September 2008, a 70 years old female was diagnosed with a lobular carcinoma after a core biopsy of a mass in her left breast. A month later, she underwent skin sparing mastectomy and axillary clearance, the histological examination confirmed a grade 2 invasive lobular carcinoma, estrogen receptor positive (ER+), progesterone receptor negative (PR−), and human epidermal growth factor receptor 2 negative (Her2−). There was no vascular space invasion, no in situ component and the axillary tissue included eight lymph nodes, three of those contained metastatic lobular carcinoma with extracapsular spread. A CT scan to chest and abdomen and a bone scan showed no evidence of any metastatic disease. Subsequently, she had radiotherapy and was started on adjuvant hormonal treatment, but because of her past medical history which includes previous nephrectomy for pelvic ureteric junction (PUJ) obstruction 10 year ago, arthritis and essential hypertension, chemotherapy was not considered. In early 2010, the patient was referred to the Department of Plastic Surgery for breast reconstruction, as she continued to show no clinical evidence of any recurrence, she underwent reconstruction with a pedicle transverse rectus abdominis myocutaneous (TRAM) flap.\nOne month later she had multiple episodes of abdominal pain and constipation which needed hospital admission. A CT scan showed evidence of small bowel obstruction (); a laparotomy and resection of a thickened and narrowed terminal ileum were carried out followed by bowel anastomosis. The histological analysis confirmed the presence of widely infiltrated small bowel by well-differentiated epithelial cells, some of which contained intracytoplasmic lumina and formed a sin", "role": "user" }, { "content": " gle file pattern of infiltration (). <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "We report the case of a 60-year-old woman admitted to the emergency department following a minor road traffic accident. The patient had a medical history of breast infiltrating ductal carcinoma (HER2+) under trastuzumab monotherapy for seven months and had been submitted to chemotherapy with FEC regimen (5-fluorouracil, epidoxorubicin and cyclophosphamide) four years before trastuzumab initiation. The patient had recently been diagnosed (six weeks before) with hypert", "role": "user" }, { "content": " ension and started treatment with <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 70-year-old woman with interstitial pneumonia suddenly ", "role": "user" }, { "content": " lost consciousness. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 40-year-old gravida five, para four woman presented for workup and management of abnormal uterine bleeding. Her past medical history was significant only for hypertension and anemia. On review of her social history, she admitted to drinking six packs of beer on the weekends but denied further substance use. She denied previous treatments for her bleeding including any previous intrauterine device usage.\nUltrasonography revealed a 7 cm fundal fibroid with otherwise normal pelvic anatomy. She was initially offered medical management of her bl", "role": "user" }, { "content": " eeding. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 93-year-old woman was referred to our outpatient clinic for management of acute corneal perforation in the left eye. She had undergone surgery for pterygium of the left eye at the age of 44 years and was treated with topical MMC postoperatively, although she could not recall the MMC concentration used or the duration of administration. Cataract surgery had also been performed on the left eye at the age of 84 years. She had no history of visual problems or symptoms, and there was also no history of diabetes or collagen diseases including rheumatoid arthritis. One month earlier, she had complained of pain in the left eye and a limbal corneal ulcer had been diagnosed by her primary care physician. She was treated with topical medications, but the ulcer became progressively worse and corneal perforation occurred. At her first visit, best-corrected visual acuity was 20/60 in the right eye and counting fingers in the left eye. The intraocular pressure (IOP) was 19 mmHg on the right and 6 mmHg on the left. Slit lamp examination of the left eye revealed a corneal ulcer near the inferior nasal limbus and collapse of the anterior chamber Fig. (). In addition, the uvea near the limbus showed dome-shaped prolapse under the conjunctiva. Focal stromal scarring from previous cataract surgery was seen in the superior temporal limbus. On the next day, urgent penetrating keratoplasty was performed using a donor cornea together with vitrectomy. The graft was attached to the nasal cornea and sclera of the patient with interrupted 10-0 monofilament nylon sutures. A transfixing suture could not be placed at the site of perforation because of corneal melting and thinning. The conjunctiva had covered the exposed uveal tissue in the region of the inferior nasal scleral defect, so additional scleral patch grafting was not performed. The anterior chamber reformed on the first day after surgery Fig. (). Her postoperative course was uneventful and visual acuity of the affected eye was 20/500 at 12 months after s", "role": "user" }, { "content": " urgery (Figs. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A healthy looking, 50-year-old Nepali man came to our clinic with a complaint of multiple growths on his scrotum for 15 years. The growths started as a single lesion on the right side of his scrotum, with the gradual appearance of similar lesions on other parts. Several of these lesions coalesced at various places to form large-sized nodules. The condition was mostly asymptomatic with an occasional complaint of itching. There was no history of pain, burning sensation, trauma, ulceration, or discharge. The lesions did not interfere with urination or sexual activities. He was worried because of the increasing size of the growth and hence came to us for advice. He did not give a history of ", "role": "user" }, { "content": " any systemic illness including metabolic, autoimmune, or malignant disorders. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 71-year-old man of normal stature presented with numbness in his left upper extremity and difficulty walking. Physical examination revealed apparent myelopathy and slight weakness of his left hand. Reflexes were symmetric throughout the upper and lower extremities.\nMagnetic resonance imaging (MRI) of the cervical spine showed C3–C7 degenerative spondylosis with mild central canal stenosis and high-signal lesions in the spi", "role": "user" }, { "content": " nal cord (). <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 72-ye", "role": "user" }, { "content": " ar-old female patient presented to the emergency department (ED) <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 43 year old male visited t", "role": "user" }, { "content": " he clinic complaining about the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The liver graft was from a young male patient, 20 years old, who weighed 57 kg, was 1.78 meters tall, and had a body mass index (BMI) of 18 kg/m2. He was admitted to a general hospital with a subarachnoid hemorrhage and intracranial hematoma on the left side, and he suffered brain death. He had a previous pathological history of SCA and was treated for his anemia with several blood cell therapies and a splenectomy when he was 16 years old. He was receiving ceftriaxone, meropenem, and vancomycin when he was submitted to donor surgery, five days after the neurosurgery. He was under low doses of vasopressors: norepinephrine (0.18 mcg/kg/min) and vasopressin (0.02 mcg/kg/min). The best suitable recipient was chosen by balancing the risk of a hematological disease or thrombotic risk factors associated with the recipient remaining on the waiting list and either dying or dropping out of the list. All laboratory analysis and liver function of the donor were normal. After all analysis and arguments discussed with the transplant team (surgeons, hepatologists, and infectologists), as risk of using SCA graft, probabilities of developing disease, and a few case reports in the literature, on the other hand, the benefits of being an excellent hepatic graft option, the recipient and her family were informed of all risks and probabilities, and a unanimous informed consent decision was made to receive the donor liver and follow with the transplant. The donor surgery was fine and was not associated with any complications. Both of the deceased patient's kidneys and liver were donated to t", "role": "user" }, { "content": " hree different recipients in different centers. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 15-year-old female with no significant past medical history presented after being struck in the face by a ball while playing water polo. The patient felt pain in her jaw, which was the chief complaint when she presented to the emergency department. Upon neurological assessment, the patient complained of midline tenderness from the skull base to midline cervical spine over C3; denied headaches, changes in vision, speech or swallowing, extremity weakness or paresthesias. A maxillofacial computed tomography (CT) scan did not show evidence of an acute facial fracture. However, the CT scan did reveal a radiolucent, ovoid-shaped lytic lesion arising in the left lateral mass of C1, between the anterior tubercle and the transverse process. Magnetic resonance imaging (MRI) studies further confirmed an enhancing osseous lesion at the left lateral mass of C1, with cortical breach and extension into the left lateral atlantodental joint space (). Of note, three years prior, patient had a CT cervical spine which, upon retrospective review, demonstrated a similar but much smaller lesion.\nDifferential diagnoses underlying this vertebral cortical erosion included those of infectious etiology, as well as oncologic lesions, such as giant cell tumor of b", "role": "user" }, { "content": " one, aneurysmal bone cyst, osteoblastoma, <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 20-year-old unmarried girl was admitted with primary complaints of lower back pain, progressive proximal muscle weakness of lower limbs for the past 4 ½ years and bony pain in both thighs and in pelvic region for the past 4 years. Four years ago she had one episode of sudden onset flaccid weakness of all four limbs associated with neck muscle weakness. At that time, there was no history of seizures, change in sensorium, and bladder or bowel involvement. She recovered completely within 24 hours after treatment with intravenous fluids. Her symptoms, however, progressively worsened and for the past 2 years, she has started having difficulty in walking. She denied any history of weakness or bony pain in the upper limbs. She was treated with oral calcium and injectable vitamin D without any relief of her symptoms. In January 2010, she developed spontaneous pain in her right thigh without any history of trauma and was diagnosed to have a fracture shaft of right femur and was managed conservatively. In the 1st week of July 2010, she developed another fracture of the left femur diaphysis after trivial trauma. At this juncture she consulted an orthopedic surgeon, who suspected MBD and referred her to the Endocrinology department for further investigations. She gave a history of grittiness and foreign body sensation in bot", "role": "user" }, { "content": " h eyes and also history of dryness of mouth for <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 65-year-old female with a history of hypothyroidism and essential thrombocytosis (on hydroxyurea) presented with complaints of acute-onset nausea, vomiting and diarrhea 2 days prior to admission. She had eaten seafood at a local restaurant the night before her symptoms started. Symptoms started within hours of eating that food. She complained of abdominal pain which was centered in the right lower quadrant and was colicky in nature. The intensity of pain varied from 6 to 7 on scale out of 10. On admission, the patient was found to be hypotensive. Abdominal exam revealed distended belly with hypoactive bowel sounds. A computed tomography (CT) scan of the abdomen done on admission did not show any acute findings. Mesenteric and portal veins were well opacified without any thrombus. The patient was given intravenous fluids and started on ciprofloxacin along with metronidazole. Despite this initial treatment, the patient's condition continued to worsen, with new-onset low grade fevers and persistent vomiting. Her abdominal tenderness worsened and bowel sounds remained hypoactive. A repeat CT scan on Day 3 of admission showed evidence of high-grade small bowel obstruction along with mucosal edema. It also showed thrombus in superior mesenteric vein (Fig. ) and portal vein with early gangrenous changes of small bowel. Based on these radiographic findings, she was taken for urgent laparotomy. Intraoperative findings included gangrene of the small bowel starting from 35 cm distal to the duodenojejunal flexure to the mid-transverse colon with no perforation. The superior mesenteric vein was thrombosed with cord like appearance. Based on these", "role": "user" }, { "content": " findings, the patient underwent a near-total small bowel resection. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 77-year-old man presented to a gastroenterology outpatient clinic with epigastric pain, dyspepsia, and early satiety lasting 10 days after the consumption of persimmons. He had underg", "role": "user" }, { "content": " one medical treatment for ulcers in <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 45-year-old South Asian woman presented with a progressively worsening of proximal muscle weakness. Initially there was a mild pain in her thighs and arms which was followed by a difficulty getting up from the seated position and inability of raising her arms. There was no dysphagia, regurgitation or difficulty in breathing. During this particular presentation there was no dermatological manifestations suggestive of dermatomyositis or mechanic’s hands. There was no history suggestive of Raynaud’s phenomenon or any joint pains. There was a mild nonproductive cough which developed a few weeks after the onset of the muscle symptoms without any notable shortness of breath of exertion or wheezing. There was no other evidence of any connective tissue diseases.\nThere was no ptosis, double vision or fatiguability to suggestive myasthenia. Patient appeared to be clinically euthyroid without any overt features of hypothyroidism. There was no history of statin use at the time of the presentation or prior to that. Patient denied any similar history previously nor was there a history of a similar disease among her family members.\nExamination revealed bilateral symmetrical proximal muscle weakness with a muscle power of 4/5 in all four limbs. Reflexes were intact without any muscle wasting. There were no overt features of dermatomyositis. Auscultation of the lungs revealed a few bilateral basal fine end inspiratory crepitations suggestive an interstitial lung disease. Second heart sound was of normal intensity. A diagnosis of inflammatory myositis was considered with a concurrent interstitial lung disease. With this clinical text she was thoroughly investigated.\nCreatinine phosphokinase levels were elevated with a value of 1435 u/l. Inflammatory markers were elevated with a ESR of 54 though the CRP was only slightly elevated. ANA was negative. Findings on electromyography was consistent with an inflammatory myositis. Muscle biopsy which was carried out revealed inflammatory cells ", "role": "user" }, { "content": " in between the muscle fibers causing complete necrosis of <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 25-day-old term baby female presented with neonatal jaundice and hyperbilirubinemia. A biliary cyst and a contracted gallbladder were diagnosed in a post-natal ultrasound from another institution. She was transferred to our hospital at day 19 of life. A repeat ultrasound showed a small gallbladder (length 1.7 cm; diameter 0.3 cm) connected to an extrahepatic cystic structure, which measured 1.4 × 0.6 cm (). The content of the cyst was anechoic and there was no dilatation of intrahepatic bile ducts. A hepatobiliary iminodiacetic acid scan on day 26 of life showed no biliary drainage up to 28 h. A PTTC on day 35 of life showed there was prompt opacification of the known extrahepatic cyst, followed by visualization of a small gallbladder. There was no passage of contrast into bile ducts or the duodenum. Aiming to demonstrate that there was no communication of this cyst with the biliary system as well as to mechanically remove any source of obstruction, the contrast injection was sustained until there was an extraperitoneal perforation of the cyst () (radiation dose: 1.1 mGy). The rationale to sustain the injection was to demonstrate a connection of the cyst with the biliary tree and our experience that there may be a benefit of mechanical lavage of the biliary tract in cases of obstruction by secretions or sludge, which has been reported by our institution in neonates with parenteral nutrition-related cholestasis. An uncomplicated ultrasound-guided biopsy wa", "role": "user" }, { "content": " s performed. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 65-year-old man was referred to our Department with a right cervical mass on April 2005. There was no apparent family history of endocrine disorders. The patient had not undergo any previous external radiation therapy. Blood pressure was normal. His serum levels of calcium, thyroid stimulating hormone and free thyroxine were normal. The baseline serum calcitonin level was 294 pg/ml (normal < 100 pg/ml). There were no antithyroid autoantibodies. On physical examination a rough nodule, about 4 cm in size, was palpated on the right side of the neck. The ultrasonography (US) showed a heterogeneous nodule, 4 cm in size, in the right lobe of the thyroid and multiple nodules with accompanying calcifications in the left lobe. A single fine-needle aspiration biopsy of the right lobe nodule revealed giant cells with enlarged nuclei and metachromatic cytoplasmic granules. Abdominal US was negative for adrenal nodules as well as urinary catecholamines and metanephrine levels were within normal limits. Total thyroidectomy plus central compartment lymph node neck dissection were performed. Macroscopically the right thyroid lobe measured 7 × 4 × 3.5 cm, left lobe of the thyroid measured 4.3 × 2.5 × 2 cm. There was a right solitary white well-circumscribed nodule of 4 cm in size, associated with a small nodule of 0.4 in the isthmus and a nodule (diamet", "role": "user" }, { "content": " er 0. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 57-year-old male presented to the oral and maxillofacial surgery clinic at our institution with more than a 20-year history of a painless mass in the hard palate region. He elected to have the lesion evaluated due to its increase in size, although indolent. He reported no other symptoms.\nHis past medical history was significant for hypertension and hyperlipidemia. He denies any past surgical history, he was not taking any medications, and he has no known drug allergies. He presently denies any social history but admits to tobacco use for 15 years and stopped almost 20 years ago.\nOn examination, it was noted that the patient had a firm, erythematous, raised lesion with a central area of ulceration located at the junction of the hard and soft palate on the right side. The lesion was roughly 2.0 cm × 1.0 cm in size (). There was no palpable lymphadenopathy on head and neck examination.\nComputed tomography (CT) and magnetic resonance imaging (MRI) showed a mass involving the right palate measuring 39 mm in the greatest dimension. The CT showed a focal area of bone thinning and focal dehiscence at the floor of the right maxillary sinus without evidence for frank tumor extension into the sinus (Figures and ).\nAn incisional biopsy was performed and sent for pathology. On hematoxylin and eosin stain, the tumor comprised of cells forming microcystic and glandular spaces containing eosinophilic homogenous material. The secretory material from the glandular spaces was noted to be periodic acid Schiff- (PAS-) positive and diastase-resistant (). The tumor cells had eosinophilic granular cytoplasm with low-grade vesicular nuclei and visible nucleoli (Figures and ). There were rare mitotic figures, and scattered inflammatory cells were present. A broad front pattern of invasion was noted. Immunohistochemical stains showed positivity for cytokeratin 7, SMA, p53, and CK5/6. The tumor was also diffusely positi", "role": "user" }, { "content": " ve for both mammaglobin and <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 25-year-old white male smoker patient was admitted to our hospital due to fever and right lower quadrant abdominal pain. Six years previously he suffered from perianal fistulas and underwent perianal surgery including drainage and fistulectomy. Two years later CD of the terminal ileum was d", "role": "user" }, { "content": " iagnosed with an upper gastrointestinal barium contrast study and an <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 76-year-old Caucasian man was referred to our institution for evaluation of a large open scalp wound, secondary to excision and prior radiation of squamous cell carcinoma (SCC) of the left temporal scalp (). Prior to this he had history of multiple skin lesions including actinic keratosis and basal cell carcinoma located on the chest, back, head, and upper extremities. There was no previous history of melanoma. He was diagnosed with SCC approximately 10 years prior to evaluation by our team. Treatment with Mohs micrographic surgery and a course of radiation th", "role": "user" }, { "content": " erapy were administered at that time. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 28-year-old, healthy female patient, who had a recent repeated history of miscarriage, presented with complaints of blurring of vision in both eyes. There w", "role": "user" }, { "content": " as no antecedent history of viral illness. <\|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 psychi", "role": "user" }, { "content": " atric patients is relatively common in Japan []. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 51-year-old woman presented with chief complaints of bleeding gums and chewing disability. Her medical history revealed that she had received renal transplantation surgery in 1999 and had remained in a stable condition without graft-versus-host disease ever since. She suffered from hypertension and gout, both of which were being well controlled and followed by treating physicians. Her medications at the time of initial examination including the immunosuppressive regimen (cyclosporine, prednisolone, and mycophenolate mofetil) are listed in Table . The patient was a nonsmoker who did not consume alcohol. She stated that she seldom brushed her teeth and had not flossed for a long time because of serious gum bleeding upon brushing or flossing.\nA facial exa", "role": "user" }, { "content": " mination revealed normal appearance without lymph <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 54-year-old woman presented to her primary care physician complaining of epistaxis, hematochezia, headache, and a seizure. She had a prior history of seizures. The pa", "role": "user" }, { "content": " tient was on warfarin for an unknown reason. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 28-year-old male patient presented in casualty with complaints of fever with chills and rigors with pain in the abdomen for a period of 20 days. The patient had initially taken antipyretics and antibiotics but found no effect. On clinical examination, the patient was febrile, and his abdomen was soft without any guarding or rigidity. Routine investigation showed that the patient had diabetes, which was uncontrolled. The test results indicated that the patient also had a high erythrocyte sedimentation rate along with a high total leukocyte count and a high level of positive C-reactive protein. Therefore, insulin and empirical antibiotics were started immediately. An ultrasonographic examination of the abdomen revealed hepatomegaly, chronic pancreatitis, an", "role": "user" }, { "content": " d splenomegaly with multiple splenic abscesses. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 18-year-old Caucasian male with no prior psychiatric hospitalizations was sent to the local emergency room after his parents called 911; they were concerned that their son had become uncharacteristically irritable and paranoid. The family observed that their son had stopped interacting with them and had been spending long periods of time alone in his bedroom. He had also reportedly not been sleeping well and had started talking to himself. For over a month, he had not attended school at the local community college. His parents finally made the decision to call police when their son started screaming at them; the police were monitoring him at their request, soon after he threatened them with a knife. The police took him to the local emergency room for a crisis evaluation.\nWhen the patient arrived at the emergency room, he was given intramuscular lorazepam 1 mg and haloperidol 5 mg because he attempted to strike the nursing staff and security guards. Following administration of the medication, he tried to escape from the emergency room, contending that the hospital staff was planning to kill him. The patient appeared to be internally preoccupied and his mood labile. He refused to cooperate with anyone attempting to conduct a meaningful psychiatric evaluation. He eventually slept for approximately four hours. When he awoke, he reported to the crisis worker that he had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis he was started on 30 mg of lisdexamfetamine dimesylate to be taken every morning in order to help him focus and become less stressed over the possibility of poor school performance.\nAfter two weeks, the provider increased his lisdexamfetamine dimesylate dosage to 60 mg every morning. The provider also started him on dextroamphetamine sulfate tablets (10 mg) that he took ", "role": "user" }, { "content": " daily in the afternoon in <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 9-year-old girl was examined for complaints of blurred vision in her right eye for 15 days. According to her history, her vision problem began after looking into a laser at a hotel 15 days earlier. On ophthalmologic examination, her BCVA was counting fingers from 3 meters in the right eye and 10/10 in the left eye. Anterior segment examination was normal and IOP was 14 mmHg in both eyes. On fundus examination, foveal hemorrhage was observed in the right eye, while the left eye was normal (). On OCT performed on the same day, the foveal cross-section of the right eye revealed a hyperreflective dome-shaped protrusion extending into the vitreous cavity due to hemorrhage under the ILM. The foveal pit was absent (). The left eye appeared normal. The MP test could not be performed due to patient noncompliance.\nSurgery was planned for the right eye after informing the patient about her current condition, natural disease course, and the risks and success rates associated with the procedure. Two days later, 23-G PPV, posterior hyaloid dissection and ILM peeling were performed. The patient developed no complications in the earl", "role": "user" }, { "content": " y postoperative period and was discharged with 0. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 71-year-old woman with a history of hypertension, hyperlipemia, and angina was admitted to our Department of Neurology for tinnitus in the head. On physical examination, bilateral hearing impairment was found. The cerebral magnetic resonance imaging (MRI) detected signal changes consisted with multiple cerebral infarctions and bilateral demyelination in the centrum semiovale. And the cerebral MRA detected atherosclerotic cerebral arteries and bilateral stenosis of the middle cerebral arteries (Fig. a, b). For further diagnosis, the patient underwent DSA subsequently. The total amount of iopamidol (Bracco Imaging Italia S.r.L.) administered during the procedure was 110 ml. The DSA showed that the patient had bilateral embryonic posterior cerebral arteries, 40% stenosis of the left middle cerebral artery and tortuous vertebral arteries bilaterally. There was no obvious calcification of the aortic arch; angiography of the arch using 25 ml iopamidol was performed only once. Ten minutes after the aortic arch angiography, the patient experienced mild headache. The pain was bearable, and the patient could cooperate during the remainder of the procedure. The DSA was completed 20 min later. No haemorrhage or vasospasm was detected during the procedure. ", "role": "user" }, { "content": " The headache was continuous, and <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 40-year-old previously healthy woman underwent a curative resection of the medical compartment of the right thigh for a malignant spindle cell tumour. Due to clear resection margins and absence of any metastatic deposits in imaging, she was not given any adjuvant therapy. She was followed up for 5 years, and she was otherwise well and asymptomatic without any evidence of local recurrence.\nAfter a period of 5 years, she developed an acute onset generalized severe abdominal pain and collapsed. She did not have any external bleeding manifestations such as haematemesis or melaena. There was no history of abdominal trauma. She was immediately admitted to the emergency department, and she was found to be in class III haemorrhagic shock with a pulse rate of 125 beats per minute and a blood pressure of 90/60 mmHg. Her abdomen was distended and diffusely tender. She was immediately resuscitated with intravenous crystalloid boluses and blood transfusion. Her serum beta-Human Chorionic Gonadotropin (beta-HCG) was negative, excluding a ruptured ectopic pregnancy. Her full blood count revealed a haemoglobin level of 5 g/dl, and a massive transfusion protocol was initiated. Her other basic investigations and clotting profile were within normal limits. Despite resuscitation, her vital parameters did not improve and her abdominal girth was gradually increasing. The abdominal ultrasound scan revealed moderate amount of free fluid with a mass around the proximal part of the pancreas. There was no evidence of abdominal aortic aneurysm, and other solid organs were normal. Hence, a decision was taken to proceed with an emergency exploratory laparotomy. A computed tomography was not done as the patient was haemodynamically unstable.\nA midline laparotomy was performed. There was 4.5 litres of haemoperitoneum, and a linear tear in the gastrocolic omentum with a haematoma in the lesser sac. Active bleeding was noted from a nidus which was situated posterior to the body of the pancreas, and it had ", "role": "user" }, { "content": " ruptured through the inferior border of the pancreas. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 58-year-old woman underwent a RYGB procedure at another institution in 2003. The procedure was successful and resulted in the creation of a 40-cc gastric pouch. The patient completed counseling for eating disorders before and after her original surgery. Unexpected events in her life, however, brought on depression, and she subsequently returned t", "role": "user" }, { "content": " o overeating, which resulted in dilation of the gastric pouch <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 24-year-old right-handed male college student presented wit", "role": "user" }, { "content": " h right shoulder pain and limited <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "In February 2019, a 50-year-old Chinese male patient visited our department due to a gradual onset of shortness of breath and palpitations. He was initially diagnosed with nonkeratinizing NPC in 1999 and had complete resolution of symptoms after radiotherapy and systemic chemotherapy (concrete primary treatment and staging was unknown). Overall health parameters during treatments were recorded (). Echocardiography suggested a hypoechoic mass spanning the left ventricle and the anterolateral right ventricle (92 × 45 × 108 mm3). The boundary between the left ventricle wall and the muscular layer was unclear (the upper part reached the level of the main pulmonary artery, and the lower part reached the level of the apex of the heart), and the arterial blood flow signal was detected (). The chest computerized Tomography (CT) scan with contrast enhancement showed an increase in heart shadow. Furthermore, a round, soft-tissue mass of 88 × 83 × 109 mm3 appeared at the left edge of the Cardiac margin, with enhanced heterogeneity. Multiple lymph node shadows were observed at the left hilum of the lung and mediastinum, and the left cor", "role": "user" }, { "content": " onary artery was wrapped (). <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The patient is a 35-year-old man and ", "role": "user" }, { "content": " a petroleum engineer. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 64-year-old male was admitted to the orthopaedic ward with fever. He had a past medical history of smoking, nephrolithiasis and paraplegia following a motor accident 30 years ago. The patient suffered a mid-shaf", "role": "user" }, { "content": " t fracture of his left femur 12 <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "This is a 60-year-old man who presented with gum pain of one-month’s duration. His pain emanated from an area of ", "role": "user" }, { "content": " exposed jaw bone in the left lower posterior gum. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 35-year-old male patient visited the King Khalid Universi", "role": "user" }, { "content": " ty dental clinic for the replacement of both maxillary and <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 30-year-old Sri-Lankan woman presented with left flank pain. The pain was intermittent, sharp, and of moderate severity and radiated to the groin. The patient reported no history of lower urinary tract symptoms or gross hematuria. The pain was associated with weight loss of 8 kg over a period of 3 months. Her medical and surgical history was not significant, and the patient was not on any regular medications.\nThe patient was afebrile on presentation with no microscopic hematuria. On physical examination, the abdomen was soft with minimal tenderness over the left flank, and a palpable left upper quadrant mass was present. The rest of the clinical examination revealed normal findings.A computed tomography (CT) scan showed a large left upper quadrant mass measuring 17 × 13 × 12 cm in its greatest dimension. The mass crossed the midline and compressed the stomach, spleen, pancreas, and small bowel (Figures and ). The origin of the mass was unclear, and the differential diagnoses included a left adrenal mass, left upper pole renal mass, and retroperitoneal sarcoma. A functional adrenal work-up was performed according to the Canadian Urological Association guidelines and included measurement of serum aldosterone, potassium, renin, and adrenocorticotrophic hormone levels; a dexamethasone suppression test; and measurement of 24-hour urinary metanephrine levels. All results were within the reference ranges.\nThe metastatic work-up included CT scans of the head and chest and a bone scan. The head CT scan revealed normal findings. The chest CT scan showed a 1.8-cm nodule in the medial le", "role": "user" }, { "content": " ft lower lobe, close to the posterior <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 67-year-old man was admitted to our department following a high-speed road traffic accident. He was sited at the back of a car when a lateral-frontal collision happened crushing the back door to his left shoulder. He sustained an open, Gustilo-Anderson IIIA fracture of the proximal humerus with a large overlying sword-like contaminated wound and significant skin loss (). There was no neurovascular deficit to the distal forearm and hand. He sustained also fractures of the 1st, 2nd, and 6th rib without any intrathoracic injury. Plain radiographs and CT scan indicated an anteroposterior directed head-splitting fracture of the humeral head involving ~30% of the lateral articular surface with a sagittal extension pattern of the greater tuberosity and without any evidence of humeral head dislocation (Figures and ). He was transferred immediately to the operating theatre as there was uncontrolled bleeding from the wound and hemoglobin level had been dropped by 4 degrees during resuscitation.\nAt surgery, thorough debridement was carried out and foreign bodies (glass particles) were removed where possible. There was a large circumferential wound to the deltoid involving its anterior, middle, and part of its posterior fibers. The platysma muscle was also ruptured exposing the medial a", "role": "user" }, { "content": " nd lateral end of the clavicle. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 76 year old woman presented with a 12 month history of hypoglycaemia symptoms. The patient underwent a series of tests including measurement of overnight fasting plasma glucose, measurement of plasma levels of glucose; insulin; and c-peptide during a hypoglycaemic episode, measurement of urinary sulphonylurea, and radiological imaging with a CT scan. Abdominal CT scan demonstrated a 13 mm insulinoma localized in the tail of her pancreas. She was commenced on diazoxide and later underwent surgery for enucleation of insulinoma when a small (< 1 cm) incidental tumour was discovered on her stomach wall. The small incidental tumour was an exophytic gastric wall lesion that had not been detected pre-operatively and revealed no suspicious features suggestive of invasion or spread on intra-operative inspection. For this reason the lesion was excised with diathermy off the surface of the gastric wall, the defect being closed with Polydioxanone suture, and no frozen sections were taken to assess invasion/spread. Macroscopically the lesion was completely excised. The ", "role": "user" }, { "content": " nature of the lesion was unknown at this time. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 10-year-old girl with non-contributory medical history reported to the Department of Pediatric Dentistry, Government Dental College and Hospital, Nagpur for the treatment of pain and swelling in maxillary anterior region. History revealed trauma to maxillary anterior region 6 month back while playing in school. Clinical examination revealed fractured and discolored permanent maxillary right central incisor. Soft-tissue examination in relation to permanent maxillary right central incisor showed soft-tissue swelling of 1 × 1 cm. The tooth was tender to vertical percussion and showed negative response to thermal (cold test [Polfofluorange Pharma Dental Handelsges]) and electric pulp testing (Parkell Farmingdate). Intraoral periapical radiograph of permanent maxillary right central incisor revealed incompletely formed apex with periapical rarefaction []. The tooth was diagnosed with a pulpal necrosis and chronic periapical abscess. After rubber dam isolation and gaining access to the root canal system, the canal debris was loosen with minimal instrumentation and the root canal system was slowly irrigated with 0.5% sodium hypochlorite to prevent further damage to the survived apical papilla. Minimal instrumentation within the root canal system prevents further weakening of the root canal system. A light plain cotton pellet was placed in the pulp chamber for 48 h to facilitate purulent drainage. At the next visit working length was measured using diagnostic radiograph, followed by very minimal instrumentation and copious irrigation with normal saline and the canal was dried with sterile paper points. Mixture of ciprofloxacin, metronidazole and minocycline (3 Mix) was placed in the canal and coronal access was sealed with zinc oxide eugenol cement (Dentifiss India Ltd. Mumbai). Patient was recalled after 1 week, the tooth was asymptomatic and the canal was found to be dry.\nA 23 gauge sharp sterile needle was pushed with a sharp stroke beyond the working length of the canal into the periapical tissue to intent", "role": "user" }, { "content": " ionally induce bleeding into the canal. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "Informed consent for publication of the case details and accompanying images has been obtained from the patient's next of kin.\nA 20-year-old man was admitted to the hospital because of headache in 2005, and then diagnosed as the pineal YST. Following SRS, the patient's symptom was relieved. In late 2013, he presented with symptoms of headache, polydipsia, and polyuria. Brain magnetic resonance imaging (MRI) demonstrated the presence of a mass in the medial tail of the left lateral ventricle, which was confirmed to be a YST by ", "role": "user" }, { "content": " the postoperative pathology. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "In late 2016, a 61 year old non-smoking female presented with exertional shortness of breath, mild pedal edema, distended neck veins, and a recent weight gain of 15 lbs over the prior 2 weeks. It was initially suspected that the patient was experiencing pulmonary embolism based on her clinical presentation and elevated D-dimer, but further testing revealed that she was experiencing cardiac tamponade with mild pulmonary hypertension and heart failure. Pericardiocentesis was performed without definitive diagnosis. In February 2017, the patient exhibited worsening respiratory symptoms without fever, hemoptysis, sputum production, B symptoms, or extremity edema. Baseline chest PET-CT images were reviewed by radiologists at both UCLA Oncology and Texas Tech University Health Sciences Center, demonstrating a large middle mediastinal mass encasing the main pulmonary artery, with pericardial and left pleural effusion (Figure & Figure ). Scattered pulmonary nodules and hypodense lesions were identified in the right lobe of the liver, consistent with a diagnosis of metastatic disease (Figure ). Biopsy of the mediastinal mass revealed a high grade undifferentiated malignant neoplasm composed of highly proliferative (ki67 staining ~50%) pleomorphic anaplastic epithelioid malignant cells with large areas of necrosis and fibrosis. Immunohistochemistry revealed strong antigenicity for CD31 and CD34, and weak antigenicity for D2-40 and Factor VIII indicating a diagnosis of angiosarcoma that was corroborated at both UC San Diego Health and MD Anderson.\nConventional treatment options were recommended, however the patient declined these based on low reported survival rates, and instead, requested the non-selective beta blocker propranolol as a single agent therapy. In May 2017, 40 mg/kg propranolol was administered daily and PET-CT scans were performed at regular intervals to assess the response of the tumor to propranolol. Assessment of tumor response was based on 18F-fluorodeoxyglucose (FDG) tracer uptake and measurements/asses", "role": "user" }, { "content": " sments of the primary tumor and distant metastases. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "62-year-old Caucasian female with a history of hyperlipidemia and osteopenia presented to an outpatient family medicine clinic after suffering a wild canine bite. The patient received standard rabies prophylaxis and subsequently underwent treatment with trimethoprim-sulfamethoxazole. 19 days later, the patient presented to an outside emergency room complaining of fatigue, dizziness, and multiple falls related to balance difficulty. After admission, the peripheral blood count reveal", "role": "user" }, { "content": " ed a white blood cell count of 1. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 16-year-old girl presented with transient left upper and lower limb numbness and headache while participating in chorus and sports. She was referred to our department for surgical treatment. She had a past medical history of immunoglobulin A nephropathy and was being treated with steroids. Magnetic resonance (MR) images showed no ischaemic changes in her brain, but MR angiography showed intracranial vascular stenosis []. Digital subtraction angiography showed bilateral stenoses from the terminal portion of the ICA to the proximal parts of the middle cerebral and anterior cerebral arteries []. Extended perforating branches were also noted. Single-photon emission computed tomography (SPECT) imaging showed decreased cerebral blood flow (CBF) on the right side [], which worsened after an acetazolamide challenge []. Based on these findings, she was diagnosed with Suzuki Stage 2 moyamoya disease bilaterally[] and underwent revascularisation on the symptomatic right side.\nDuring surgery, both direct and indirect bypasses were successfully performed; however, involuntary movements appeared immediately after the operation, with her right upper limb episodically shaking at a frequency of 3 to 5 Hz []. These episodes lasted for a few minutes up to a few hours, with no associated disturbances in her level of consciousness and no incontinence. The involuntary movements were limited to the right upper limb and did not occur during sleep. On the next day, MR angiography showed good patency of bypass vessels, and MR images showed neither cerebral infarction nor hemorrhage [ and ]. Electroencephalography (E", "role": "user" }, { "content": " EG) showed no abnormal brainwaves suggestive of epilepsy. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 24-year-old healthy woman, without a significant medical family history, presented with a lump in the lower inner quadrant of her left breast 24 months prior to her referral to our center. At that time, the mass was diagnosed as a benign lesion after incisional biopsy. She became pregnant and about 1 year after child delivery, the left breast mass grew significantly larger. On clinical suspicion of malignancy with global infiltration of the left breast, she was referred to our center. Mammography showed an asymmetric increased density in the left breast. Multiple-site core needle biopsy was performed, but it led to no definite pathological diagnosis. Consequently, the patient was scheduled for open biopsy. Under general anesthesia, the mass was entered via an incision on the most prominent site. After the removal of a 2×2 cm tissue biopsy, a cavity was opened beneath the excised tissue which was full of blood clot. Following the removal of the clot, active bleeding occurred. Bleeding was diffuse and uncontrollable, such that within a few minutes, the patient lost about 1500 cm of blood. Effective packing was performed. The next day, after the patient had stabilized, she was retransferred to the operating room for the removal of the pack. However, due to severe bleeding after the removal of the pack, packing was reapplied. Chest computed tomography scan revealed a large, well-enhanced mass in the left breast without invasion to the skin or pectoralis muscles and also enlarged left axillary lymph nodes ().\nAccording to the final pathology report, histological sections of the mass demonstrated a vascular tumor with interconnectin", "role": "user" }, { "content": " g blood channels lined by atypical, pleomorphic endothelial cells. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 20-year-old male patient presented with a history of pain in the left hip for the past 6 months. The pain was insidious in onset, intermittent, occurred predominantly at night, progressively increasing with time, 6/10 on a visual analog scale and was present over the anterior aspect of the left hip. It was non-radiating and there were no aggravating factors for pain. However, he got some relief with over-the-counter analgesics. There was no history of antecedent trauma and the remaining history and general examination did not reveal any significant abnormalities. Local examination revealed diffuse tenderness over the anterior aspect of the left hip. There was no palpable swelling or wasting of the leg muscles. The range of motion of the left knee and ankle joints was normal and there was no", "role": "user" }, { "content": " neurovascular deficit distally. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The patient is a 39-year-old woman without any comorbidities, G1 P1. She came to hospital with a chief complaint of “a watery vaginal discharge for 9 months”. She had regular menstrual periods, with a menstrual cycle of 5–7 days/30 days, moderate menstrual flow and no dysmenorrhea. She had one vaginal delivery in 2005, patient’s father suffered from rectal cancer, and her younger sister suffered from gastric cancer.\nIn September 2018, first symptom emerged as a large amount of vaginal discharge without any incentives, and the nature of the secretions was clear and odorless. The patient claimed no abdominal pain with twice postcoital bleeding.\nIn October 2018, cervical and gynecological ultrasound at the local hospital showed no abnormalities, oral medication was prescribed (drug unknown), and the symptoms were not relieved.\nThe patient was referred to a tertiary center in February 2019, where LCT was rechecked as negative and HPV test was not checked.\nIn March 2019, the patient came to our hospital. In her gynecological specialist examination and after using the speculum, there was a large amount of clear secretion in the vagina, which was colorless and odorless. The cervix had a hypertrophic appearance and a barrel-like appearance. There was no obvious contact bleeding when wiping the surface of the cervix with a cotton swab. In the bimanual gynecological examination, the cervical hypertrophy can be felt, with clear contour, and the tactile feedback is hard and slightly resilient. The vaginal fornix is soft and has no obvious mass. No masses were touched on both sides of the para-uterine spaces. In the trimanual gynecological examination and digital rectal examination, soft rectal mucosa was touched without abnormal masses. No other abnormality was found during the palpation of the uterus and bilateral adnexal area. The imaging consultation of MRI scan in our ", "role": "user" }, { "content": " hospital has the following findings: 1. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "We present a case of a 69-year-old female with a past medical history of multiple myeloma followed by autologous peripheral stem cell transplant who was hospitalized after presenting with worsening dyspnea. Prior to her stem cell transplantation, she was found to have pulmonary Cryptococcus neoformans infection and was placed on oral flucytosine and intravenous liposomal amphotericin B. Subsequent studies revealed no central nervous system (CNS) involvement, and flucytosine was discontinued. She was discharged from the hospital to complete two weeks of intravenous liposomal amphotericin B and a year of oral fluconazole. She was readmitted after two weeks due to constitutional symptoms of fever, loss of appetite, and fatigue in addition to dry cough. Cryptococcus serum titers were 1 : 640 during this time as compared to 1 : 2560 at dia", "role": "user" }, { "content": " gnosis. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "In March 2018, a 60-year-old man presented to a private dental clinic with a history of painful swelling in the right angle of the mandible. The patient reported that in December 2017, he had visited another local dental clinic with a chief complaint related to pain in the right posterior mandibular region. His past medical history included controlled type 2 diabetes. The dentist requested a panoramic radiograph, and the diagnosis was a periapical infection related to the right third molar and badly decayed right second molar, and an extraction was performed based on the patient's history. After extraction, the patient reported continuous pain with an unhealed socket, and an antibiotic regime was initiated. As a result of the unresolve", "role": "user" }, { "content": " d pain, and without a prescription from his physician, he <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 67-year-old man presented to clinic with 4 months of increasing diarrhoea and weight loss from 74 to 60 kg. He had a height of 1.91 m and a body mass index of 16.4. He opened his bowels up to 8 times a day with loose motions, though without associated blood or mucus, and had not improved with trials of gluten-free and lactose-free diets. Prior to this, he had never had gastrointestinal symptoms. His past history was significant for Klinefelter's syndrome requiring parenteral testosterone replacement, 2 previous lumbar laminectomies, and chronic obstructive pulmonary disease with a 30 pack-year history of cigarette smoking that had ceased 4 years prior.\nMultiple outpatient investigations were performed, all with negative results. These included full blood count; renal function and liver function tests; serum levels of iron, vitamin B12, folate and albumin; erythrocyte sedimentation rate and C-reactive protein; thyroid function tests; serology for human immunodeficiency virus hepatitis B and hepatitis C; stool cultures and parasite screening, and anti-tissue transglutaminase antibodies. Computed tomography (CT) scans of his chest, abdomen and pelvis revealed only a 1-cm left adrenal adenoma which appeared benign, uncomplicated cholelithiasis and atheroma within the abdominal aorta. Gastroscopy and colonoscopy were macroscopically unremarkable, with biopsies of the stomach, duodenum, terminal ileum and colon showing no abnormalities.\nOn a second clinic review 2 months later, his symptoms had progressed to include nausea beginning 1 h after meals, persisting for several hours and causing secondary anorexia. His diarrhoea continued, and a further kilogram of weight had been lost. Further outpatient tests included a nuclear medicine gastric emptying study with a negative result; although faecal calprotectin via the Quantum Blue method was elevated at 145 μg/g, indicating a high probability of inflammation in the gastrointestinal tract.\nThree weeks later, prior to a planned clinic appointment, he was admi", "role": "user" }, { "content": " tted to the hospital with ongoing nausea and diarrhoea <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 31-year-old man was admitted to our hospital, complaining of hematochezia which had lasted for 1 month. His past history involved a high anterior resection of the rectum in our hospital due to intussusception caused by Peutz-Jeghers polyposis (Fig. ). He was hospitalized for 1 month after the procedure. Unfortunately, details of the surgical procedure that had been performed and the reason for his extended postoperative hospitalization were unknown, because clinical records from his previous admission were not available. He was followed up for 3 years after the procedure, during which he had no abdominal symptoms. He remained symptom-free until the month prior to readmission when he began to suffer from hematochezia. On this admission, hematochezia was his only symptom and there were no abnormal abdominal findings on physical examination. Blood test results, including levels of tumor markers, were all within normal limits. Colonoscopy revealed a hemorrhagic tumor with a smooth surface protruding from the anastomosis of the previous high anterior resection, at a distance of 10 cm from the anal verge; a second examination 4 days later revealed that the tumor had disappeared (Fig. ). The biopsied tumor and other small polyps were histologically diagnosed as adenocarcinoma and hamartomatous polyps, respectively (data not shown). We performed a low anterior resection of the rectum, including the anastomotic site with the adenocarcinoma, combined with a resection of the ileum for s", "role": "user" }, { "content": " trong adhesion. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 63-year-old woman was referred by her general medical practitioner to our Department for Oral and Maxillofacial Surgery. The patient noticed an increasing painful swelling in the right preauricular region during the past 2 years. The dental situation included a prosthetical insufficient treated status and a strong abrasion of the teeth most likely due to a supposed craniomandibular dysfunction. There was no previous history of trauma. One year before there had been an excision of a malignant melanoma (pT1a, cN0, cM0), in the skin of the left knee. The patient suffered from no severe disease besides arterial hypertonia and rhinoconjunctivitis allergica.\nPerforming an extraoral examination, there was a marked facial asymmetry with deviation of the chin to the left side and a remarkable bony hard swelling in the right condylar region. Mouth opening was possible with no pronounced clicking or crepitus.\nThe patient wore partial dentures with 5 own remaining teeth in the upper jaw and 9 remaining teeth in the lower jaw. The occlusion was an Angle Class I with correct denticulation but seemed to be a skeletal mandibular protrusion in the side profile clinically because of a prominent chin. The condyles itself looked similar in size and form ().\nIn the first sonography, unsharp circumscribed possibly calcified lesions could be seen in the cranial of the right caput mandibulae. There was no increased vascularisation to be found. Beside this, the TMJs on both sides were in a symmetric degenerative status.\nThe full extent of these lesions on the right side was defined more precisely by a computed tomography (CT) scan (). Diverse loose calcified bodies which appeared to be within and outside of the right capsule could be recognized in form of a remarkable saculation to the medial direction.\nIn a separate performed magnetic resonance imaging (MRI), lesions could furthermore be described as a cystical diagnostic finding (\n–). The suspe", "role": "user" }, { "content": " cted radiological <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 78-year-old male with nephrotic syndrome was referred to our center by his primary care physician. The patient had a history of hypertension since the age of 45 years, hypothyroidism since the age o", "role": "user" }, { "content": " f 68 years and diabetes mellitus <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 16-year-old high school girl visited the hospital in with the symptoms of depression, worry over her future, a difficulty with concentrating in class, and loss of will and appetite. Her father had died of the liver disease one year earlier; however, his death was expected, and she recalled that she was not shocked and felt rather neutral when it happened. At that time she carried on with life as normal and showed even improved academic performance.\nSix months ago, she entered a boarding school. Around this time, she began to feel fatigued everyday activities became difficult for her with no explanation. She did not speak to her classmates, lost interests in school, and could not find the motivation to continue studying. At first, she thought this was due to the change in environment and the stress from her studies. Consequently, she moved to a new school so that she could continue living at home. However, this did not help, and her grades in school became worse. One month ago, she began to think of her father a lot, which often brought her to tears.\nOn her visit to our psychiatric outpatient unit, the second author (psychiatrist) evaluated her symptoms according to DSM-IV criteria and diagnosed her with MDD. At the same time, the same author administered the Hamilton Depression Rating Scale (HDRS), and she scored 18, which was indicative of moderate level of depression. In addition, to rule out the possible diagnosis of PTSD from her father's death, the Clinician-Administered PTSD Scale (CAPS), was administered. She did not fulfill the A2 criterion, as she did not react with fear, helplessness or terror. Symptom evaluation also did not satisfy the DSM-IV criteria for PTSD, and her total score on the CAPS was 26, which was under th", "role": "user" }, { "content": " e diagnosable level. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A woman in her 80s with a 5-year history of worsening motor symptoms presented to the Movement Disorders Clinic. Her initial symptoms included difficulty walking ", "role": "user" }, { "content": " that progressively worsened alongside presence of choreic movements, involving head <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 34-year-old man presented to the emergency department with a 2-hour history of sudden acute severe back pain at the thoracic level. He described that the pain was initially dull and then became sharp. There was no history of trauma, drug use or any physical exertion. The past medical history was unremarkable. On arrival, he was conscious and alert, with no respiratory distress and normal vital signs. The rest of the physical examination was normal", "role": "user" }, { "content": " . <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 18 year old female patient was reported to the department of Oral Medicine and Radiology in Nair Hospital and Dental College; with complain of swelling on left side of face in the preauricular region. She had a history of swelling since 8 months which was slowly increasing in size. She had no prior medical or family history of treatment for any chronic infective disease. Patient was thin built and moderately nourished. The patient pre-sented with trismus and a moderate sized swelling present on left side of face in the preauricular region with no sinus or discharging pus. Overlying skin was normal in colour and ear lobule was not elevated. Swelling was tender and firm on palpation. A lymph node was palpable, tender and of 1.5 x 1.5 cm size in left submandibular area. Presence of trismus restricted examination of oral cavity; an ulcerative lesion over the retro molar region in relation to impacted 38 was seen. Tenderness was pr", "role": "user" }, { "content": " esent over the retro molar region in relation to 38. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "Our patient was a 95-year-old gentleman from a nursing home background who presented with a large, fixed, non-tender mass around his left orbit, which progressed quickly over the two-week period prior to presentation. His vision was intact, but the pressure of the mass was causing discomfort to the patient. He had obvious proptosis of the left eye and associated diplopia as the mass progressed in size.\nThe patient had a history of several non-melanomatous skin cancers in the past, which had been managed by his general physician, but no history of any haematological issues or other relevant medical history.\nWhen he first presented, it was felt to be an orbital cellulitis and treated with IV antibiotics, which did not result in any clinical improvement. A CT was then performed, which showed a mass that was invading his left orbit. It was noted that the mass extended into the left orbit from the medial side, displacing the eye and medial rectus muscle laterally (Figure ). No optic nerve involvement was seen on the CT and the mass did not encroach on the ophthalmic vessels. No destruction of bone was seen.\nThe decision was made to admit the patient to hospital for further investigations. A punch biopsy was performed, which showed extensive infiltration of the dermis, subcutis, and skeletal muscle by a neoplastic infiltrate of epithelioid cells, with decohesion. The appearance of the biopsy and the immunohistochemical profile were in keeping with myeloid sarcoma.\nThe patient’s case was discussed with both an ophthalmic surgeon ", "role": "user" }, { "content": " as well as a haematology consultant. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "Our patient was a 65-year-old Finnish male with schizoaffective disorder who was living in a local nursing home. His regular medication included chlorprothixene 50 mg twice a day, valproic acid with morning dose of 500 mg and evening dose of 1000 mg, propranolol 50 mg three times a day, and hydrochlorothiazide 12.5 mg. Propranolol and hydrochlorothiazide were prescribed previously to treat medication-induced peripheral edema and tremor. Our patient accidentally received the medication of another patient: clozapine 300 mg, theophylline 200 mg, olanzapine 30 mg, warfarin 5 mg, and 1 g of potassium chloride. Four hours after the initial dose he arrived at our emergency room for a clinical examination.\nThe first clinical examination took place 6 h after our patient took the incorrect medication. This examination was unremarkable and demonstrated that he had a soft non-tender abdomen. Results from an ", "role": "user" }, { "content": " electrocardiogram were normal and there was no tachycardia or fever. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 6", "role": "user" }, { "content": " 5-year-old woman complained of increasing pelvic <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "This 2 year-old Hispanic male has a past medical history of hypoplastic left heart syndrome (HLHS) that required multiple cardiothoracic surgeries including a Norwood procedure with a Sano shunt after birth, a bidirectional Glenn procedure at 4 months of age, and two subsequent tricuspid valve repairs. He had a right middle cerebral artery (MCA) stroke at 18 months of age manifesting as left face and arm weakness. At that time, a heterozygous prothrombin G20210A mutation was diagnosed causing thrombophilia. The stroke was medically managed. He ultimately made a full neurologic recovery and was discharged home with warfarin for the thrombophilia.\nHe was most recently admitted for acute left hemiplegia. At 1430 on the day of presentation, his mother noted that he was demonstrating some left-sided weakness that progressed to complete hemiplegia. At 1800 in the emergency department, his mentation and speech were appropriate, but the left hemiplegia persisted and his modified Rankin scale (mRS) was 4. His anticoagulation was subtherapeutic with an INR of 1.6. Suspecting a stroke, a head CT scan was obtained demonstrating an area of hypodensity within the inferior right frontal lobe suggestive of a recent infarct. To obtain more information, the patient was electively intubated and an emergent MRI was obtained (), demonstrating a complete occlusion of the proximal right M1 segment. An area of restricted diffusion was noted deep to the insular cortex involving the right lentiform nucleus and posterior limb of the internal capsule. Patchy areas of restricted diffusion were demonstrated in right frontal region and posterior temporo-occipital junction without corresponding hypointensity on the ADC map indicating subacute areas of infarction.\nGiven the findings of the MRI, the patient was urgently transferred to the endovascular suite for intervention. He remained int", "role": "user" }, { "content": " ubated and under general anesthesia while access was obtained <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "This 35 year old woman began noticing increasing fatigue in 2014. The fatigue and left lower quadrant pain became increasingly severe so that she went an emergency room. On 19 February 2018, a CT scan wa", "role": "user" }, { "content": " s performed that showed an infiltrate into the greater omentum <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 52-year-old male patient reported to the department of oral and maxillofacial surgery in view of a persistent diffuse swelling in the right lower face and neck region for 5–6 years []. The swelling remained stable in size for 4–5 years, after which it started increasing and reached the present size. The patient reported associated pain in winter season. History for associated or concurrent medical illness, trauma, fever, pus discharge, and any other similar swelling in any other part of the body was negative.\nThe swelling was irregular in shape with diffuse margins, compressible, and extending from mandibular attachment of right buccinator muscle to upper neck region. It extended anteroposteriorly from the left parasymphysis region to 2 cm beyond the right angle of the m", "role": "user" }, { "content": " andible and measured approximately 15 cm × 9 cm. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 19-year old male presented to us in the outpatient department with complaints pain on lifting weight with the right arm, deformity and limited range of motion of the right elbow for five months. The patient had fallen down and sustained the injury to his right elbow while hanging from t", "role": "user" }, { "content": " he rootlets of a Banyan tree, following which, he had <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 35-year-old G4P2012 presented to labor and delivery at full term in early labor with spontaneous rupture of membranes. She had undergone living donor kidney transplant 8 years prior for ESRD suspected secondary to IgA nephropathy versus post-streptococcal glomerulonephritis. She was maintained on Prograf and prednisone throughout her pregnancy with a stable baseline serum creatinine 1.2 mg/dL. Obstetrical history was significant for two prior uncomplicated Cesarean deliveries, both prior to her kidney transplantation. It was unclear from her records whether she had undergone counseling regarding pregnancy post-transplant. She declined a of trial of labor after Cesarean section despite counseling on the risk of injury to the transplanted kidney given its location in the operative field, which was confirmed on transabdominal ultrasound prior to the case.\nThe patient was taken to the operating room for and indicated repeat Cesarean section. Routine dissection was performed down to the level of the fascia through a Pfannenstiel incision and the fascia was carefully transected horizontally in the usual fashion. When the superior fascial edge was lifted for traction to allow for dissection from the underlying rectus muscle, brisk pulsatile bleeding was noted. The transplanted kidney was noted to be densely adherent to the overlying anterior abdominal wall, and avulsion of a portion of the transplanted kidney was confirmed (Fig. ). Direct pressure was applied to the organ while the Trauma Surgery team was consulted. The avulsion was repaired using 3–0 pledgetted Prolene sutures in interrupted horizontal mattress fashion and using Evarrest compound. At this time, the decision was made to extend the skin incision in the vertical midline for improved access to the uterus given the concern for further shearing forces to the exposed transplanted kidney in the process of d", "role": "user" }, { "content": " elivering the baby. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 67-year-old male patient was admitted to our hospital on March 20, 2020 with a complaint of sudden disturbance of consciousness. An emergency head CT scan showed 1. left basal ganglia haemorrhage with intraventricular extension, 2. bilateral lacunar infarctions at basal ganglia and senile brain degeneration, 3. mild bilateral inflammation of ethmoid sinuses. An emergency lung CT scan showed chronic bronchitis-emphysema, pulmonary bullae, and mild chronic inflammation of both lungs. Physical examination at admission showed a body temperature of 36.7°C, a pulse of 100 bpm, a respiratory rate of 21 breaths per minute, and a blood pressure of 156/92 mm Hg. The patient was in a light coma and showed no response to instructions or questions. Rough respiratory sounds were detected in both lungs, and no moist rale was detected in either of the lower lungs. Neurological examination showed eye opening and vocalization with strong pricking, binocular gaze to the left side, and pupils equal in size with a diameter of 3 mm, round, and reactive to light. No rigidity was detected in the neck and the patient could not cooperate in muscle strength examination. Voluntary movements of the left limbs were observed while no movement was observed in the right limbs. The patient could not cooperate during the examination of muscle tone or tendon reflexes. A positive Babinski sign was observed on the right side but negative on the left side, while a positive Kernig sign was present bilaterally.\nConsidering the clinical manifestations and examinations, a diagnosis of left basal ganglia cerebral hemorrhage and bilateral basal ganglia lacunar infarction were made. The symptomatic treatments were provided, includi", "role": "user" }, { "content": " ng haemostasis, dehydration to decrease intracranial pressure, and blood <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A previously healthy 57-year-old woman, with no significant past medical history, presented to the surgical department of our hospital for definite management of a primary pancreatic leiomyosarcoma, after being treated with adjuvant chemotherapy.\nOne year before her last admission, she was initially admitted to our emergency department due to abdominal pain, fatigue, and weight loss. She was totally healthy prior to these symptoms. She then underwent magnetic resonance imaging (MRI) that was indicative of a pancreatic head lesion along with possible metastatic liver lesions, superior mesenteric vein occlusion, and portal vein infiltration (Fig. a, b). The decision was to undergo an endoscopic ultrasound (EUS) biopsy in order to determine the exact nature of the lesion. EUS report was indicative of pancreatic leiomyosarcoma.\nMultidisciplinary team’s decision was to use gemcitabine- and docetaxel-based chemotherapy as up-front treatment to assess tumor response. Follow-up CT scan and magnetic resonance imaging (MRI) after the completion of chemotherapy r", "role": "user" }, { "content": " egimen showed downsizing of the pancreatic mass, as well <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 45-year-old male from the Netherlands presented with a painless right parotid swelling that was progressively increasing in size for the past 8 months. Though occasionally he suffered from jaw lock, other symptoms associated with neurologic deficit such as drooling, facial weakness, paresthesia, or auditory defects were absent. Apart from being a social alcohol consumer, there was no history of smoking, prior radiation, or significant family medical history, especially in regard to his present illness.\nPhysical examination revealed a tender right parotid swelling below the ear lobule, which extended inferiorly to the angle of the mandible (). The skin overlying the swelling was slightly erythematous, thickened, and nodular. The swelling was firm, diffused, and fixed to the underlying muscles, and there was no associated lymphadenopathy. Otoscopic examination of both ears", "role": "user" }, { "content": " was within normal limits. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 44-year-old African American male with end-stage renal disease secondary to focal sclerosing glomerulonephritis underwent sequential renal transplants. He received his first cadaveric renal transplant in 2008, and when that failed, he underwent a second cadaveric renal transplant two years later. Subsequent to transplantation, the recipient of the hepatic allograft developed cerebral melanoma metastases. The donor was not known to have a history of melanoma prior to death. Our patient was notified and further work-up was pursued. He underwent CT of the chest, abdomen, and pelvis, as well as a brain MRI. This demonstrated three indeterminate lesions on the left transplant kidney (), which were subsequently biopsied and demonstrated to be metastatic melanoma. No other foci of disease were demonstrated.\nAt this point, the patient underwent transplant nephrectomies of both kidneys; these took place approximately one year following his original transplant. Final pathology on the left kidney demonstrated 2 foci of metastatic melanoma; one focus was 1.5 cm, and the other was 1.8 cm. Vascular invasion and penetration of the renal capsule were both present. Immunohistochemical staining was performed with S100, HMB45, and MELAN-A, which were all positive. Immunosuppressive medications were tapered and discontinued.\nFour months later, the patient was referred to medical oncology for further follow up. On physical exam, he was found to have a 1 cm firm subcutaneous nodule of the left anterior thigh, concerning for a metastatic deposit. Review of his prior CT scans revealed that imaging did not include this area. Wide local excision of the thigh lesion yielded a 1-cm nodule; pathology was consistent with necrotic melanoma. The lesion was sent for BRAF genomic analysis, which was negative for mutation. A PET/CT and brain MRI were also ordered.\nThe PET scan revealed multiple foci of uptake on skin surfaces, bone, and in the subcutaneous tissues, in the extremities and abdominal wall. A left tempor", "role": "user" }, { "content": " al lobe lesion was also noted; MRI corroborated the impression <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "Our patient was a 68-year-old Australian Caucasian man who had a right above-the-knee amputation following a motorcycle accident in 1959, when he was 19 years of age. He initially perceived a painless phantom that dissipated soon after amputation. He did not have painful neuromata, but experienced paroxysmal shock-like stump pain two to three times yearly that would settle within 24 h", "role": "user" }, { "content": " ours. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A previously healthy 39-year-old female, admitted to the THP with a history of fever for 4 days. She had nausea, vomiting, arthralgia, myalgia and headache. She did not have any bleeding manifestations or abdominal pain. On examination, she had mild dehydration with low volume pulse. Blood pressure was 100/80 mmHg in supine position and 90/8", "role": "user" }, { "content": " 0 mmHg on standing. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 78-year-old Caucasian woman with no known past medical history presented to the emergency department with complaints of bilateral lower extremity edema and erythema with a clear serous discharge. The patient first noticed some small blisters on her left lower extremity which subsequently opened with some clear serous drainage. She also experienced progressively worsening swelling first of the left lower extremity and then her right lower extremity which prompted her to come into the hospital. Except for a cough, the patient had no other symptoms.\nPreliminary evaluation at the emergency department indicated the patient had cardiomegaly and bilateral pleural effusions with a BNP of 1260. She also had atrial fibrillation with rapid ventricular response. The patient was not complaining of any chest pain, fevers, chills, nausea, vomiting or diarrhea. Her chest x-ray showed evidence of cardiac enlargement with interstitial densities and bilateral air-space processes possibly associated with asymmetric pulmonary edema. Large bilateral pleural effusions were noted, with the left greater than the right side. Incidental", "role": "user" }, { "content": " ly, some evidence indicating a compression fracture of indeterminate <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 8-year-old girl with severe sternum depression and a history of exercise intolerance, fatigue, and shortness of breath on exertion was assessed. The patient also referred nocturnal dyspnea. Family history revealed an older sibling with asymptomatic severe PE that required surgical correction (Nuss procedure) at 7 years of age. Our patient's sternal depression was visible since birth and symptoms had started earlier in life (6–7 years of age), followed by rapid progression of symptoms which were more notable in the past 6 months. Genetic tests were performed to rule out Marfan syndrome as well as other abnormalities. The physical examination showed a prepubescent female with a height of 131 cm and weight of 22 kg. Her chest revealed a deep, asymmetric PE deformity (\n).\nAs part of the assessment protocol, a computed tomography (CT) scan was ordered (see\n). Chest CT evaluation showed that the sternum depression was posterior to the anterior vertebral column ren", "role": "user" }, { "content": " dering the Haller and correction index, <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "On admission the white blood count was 67.3 with a di", "role": "user" }, { "content": " fferential of 21 polys 16 bands 3 lymphocytes 2 <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "The present case report is about a 30-year-old female patient who reported with a chief complaint of swelling in relation to right maxillary canine for 5 days. Dental examination revealed a right maxillary canine with a deep carious lesion. The patient also gave history of episodic swelling in the involved tooth. Clinical diagnosis was pulpal necrosis with periapical abscess and sinus discharge. The patient gave a history of BSS which was diagnosed at the age of 5 years. Her parents, siblings and her children were free of BSS symptoms.\nPatient with BSS usually requires platelet concentrate supplement prior to dental invasive procedures and tranexamic acid to control bleeding post-operatively. The referring physician from Department of Hematology instructed us to give 1 unit of platelet rich plasma and Iron dextran for thrombocytopenia and anemia. The patient showed allergy to Iron dextran after a test dose so further infusion was given with Iron sucrose (4 ampules). There was a significant increase in hemoglobin level and platelet count [].\nAfter the consent obtained from the referral doctor and written consent from the patient root canal treatment was planned for the syndromic patient. A pre-operative radiograph was obtained, which showed periapical radiolucency in relation to maxillary right canine []. After detailed clinical and radiographic examination, the right maxillary canine was prepared for non-surgical endodontic therapy. The tooth was isolated with a rubber dam and a conventional endodontic access opening was made []. The working length of canal was estimated by means of an electronic apex locator (Root ZX; Morita, Tokyo, Japan) and then confirmed by a radiograph. The canals were initially instrumented with #15 nickel titanium files (Dentsply Maillefer) under irrigation with 5% sodium hypochlorite and 17% ethylenediaminetetraacetic acid. Coronal flaring was carried out by using gates glidden burs. Cleaning and shaping of the canals was done by using hand nickel titanium ProT", "role": "user" }, { "content": " aper file system (Dentsply Maillefer, B <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 79-year-old male was referred to the surgical outpatient department with a 2-month history of altered bowel habit. Abdominal examination and digital rectal examination in the outpatient clinic were unremarkable.\nThe laboratory studies, full blood count and biochemistry were normal. A colonoscopy study identified four abnormal lesions, two of which were colonic subcentimetre polyps. More distally in the mid-rectum, at 15 cm from the anal verge, there was a sizeable, villous polypoidal lesion, which was proved on biopsy to be a tubulovillous adenoma (TVA) showing low-grade dysplasia. More proximally in the distal sigmoid colon at 25 cm there was a segment of a malignant-looking lesion associated with a stricture (). However, biopsy samples from this region showed hyperplastic colonic mucosa showing lamina propria fibrosis and mild chronic active inflammation with separate pieces of granulation tissue and ulcer slough but no evidence of malignancy.\nAs per local protocol for malignant-appearing lesions on endoscopy, a staging CT scan was arranged on the basis of the colonoscopy appearances to facilitate the cancer pathway. This demonstrated, at the site of the presumed malignancy in the distal sigmoid colon, a 7 cm segment of circumferential thickening on a background of diverticulosis (). This was associated with a few subcentimetre locoregional and inferior mesenteric lymph nodes. There was no suggestion of malignancy elsewhere; so the proposed CT staging was T2/3 N1 M0.\nAlthough the 5 cm rectal TVA could explain the patient’s symptoms it was felt at the multidisciplinary team discussion that either lesion could be responsible for the patient’s symptoms. Despite the lack of malignant cells from the biopsy samples the surgical team were still concerned about a potential sigmoid colon malignancy from the endoscopy and CT appearances. It was felt that the colonoscopy sampling was not truly representative of the malignant appearing sigmoid colon lesion seen at colonoscopy and CT. An anterior resection was planned for the patient to remove", "role": "user" }, { "content": " both the TVA and <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 23-year-old female reported with complaints of a slowly expanding swelling of right cheek and upper jaw, pain in right upper teeth, and painful watering of the right eye of 2-3 months duration.\nHer dental history revealed that she had pain in 16 about 1½ year back and got root canal treatment done for it by a local general dentist and was apparently asymptomatic for the next 6 months. There was no history of trauma. Then she had intermittent pain in the same tooth and antibiotics were given. Later she developed a swelling on right cheek and felt severe pain so the tooth 16 was extracted by the same dentist about 3 months back. As the pain and swelling did not subside even after extraction, incisional biopsy was performed twice from the region of 16 both from the socket and vestibule by oral and maxillofacial surgeons. It was histologically diagnosed as nonspecific inflammatory lesion.\nOn examination, extraorally a swelling measuring about 4 × 5 cm with diffuse borders was seen on right cheek extending from the corner of the mouth, nose, to lower eyelid. On palpation, the swelling was firm to hard in consistency with moderate tenderness []. Skin over the swelling was reddened and compromised facial nerve function on right side on smiling was also observed. Obliteration of right nasolabial fold and mild edema over right lower eyelid was noticed. Right eye showed no change in visualacquity and eyeball movements.\nThe intraoral examination revealed a purplish discoloration with expansile mass in the right upper vestibular region extending from 13 to 17 with complete obliteration of the vestibule []. Oroantral fistula resulted after the earlier biopsies in the regions of 14, 15, and 16. There was no caries in the associated teeth but were periodontally compromised: 14, 15, and 17 showed grade II mobility and 13 and 18 exhibited grade I mobility. Signific", "role": "user" }, { "content": " ant palatal expansion in the molar region was also observed. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 10-year-old male patient presented to the Oral and Maxillofacial Surgery Unit at King Fahad Specialist Hospital, Dammam, Saud", "role": "user" }, { "content": " i Arabia, complaining of painless swelling in the <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "This is the case of a 60-year-old Caucasian male who was known to the Oncology service as he was undergoing six monthly surveillance computed tomography (CT) of the thorax, abdomen and pelvis after diagnosis of malignant melanoma which was excised from his back in 2018. At the time of diagnosis, it was a Stage IIIb lesion with 3/30 nodes positive. Adjuvant radiation was performed to the axilla at the time, but the patient was not deemed suitable for adjuvant immunotherapy because of a past medical history which was significant for dilated cardiomyopathy after previous viral myocarditis. He had an ejection fraction of 50%, atrial fibrillation and previous hepatitis also presumed to be viral.\nHis son had a melanoma removed at age 22 but given the fact he was adopted, he had no o", "role": "user" }, { "content": " ther family history to report. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 80-year-old woman presented with a history of intermittent, severe epigastric pain. Over the preceding 5 months, she had less severe and self-resolving epigastric pain 15–30 min after every meal. The full blood count, serum biochemistry values, and C-reactive protein level were within normal ranges. Additionally, arterial gas analysis was normal. Abdominal plain radiography showed free air between the liver and diaphragm, and PI (Fig. ). Abdominal computed tomography showed severe calcification of the SMA origin; SMA peripheral flow was reserved (Fig. ). Computed tomography (CT) revealed bubble-like intramural gas of the small bowel with the contrasted wall pneumoperitoneum (Fig. ).\nSince the patient did not have peritonitis, a conservative approach was performed. She was managed in the condition of intensive care unit, due to fears of the potential for acute mesenteric ischemia due to mesenteric artery occlusion or non-occlusive mesenteric ischemia. She was managed for bowel obstruction, which included fasting and intravenous fluid administration. She received heparin infusion to prevent SMA occlusion and maintain collateral flow. During admission, she reported abdominal pain relief. Seven days after admission, abdominal plain radiography showed improvement in PI and pneumoperitoneum; therefore, she was permitted to begin drinking fluids. There was no evidence of recurrent abdominal pain after the fluid consumption, so she was allowed to eat solid food.\nAngiography was planned to relieve the postprandial abdominal pain. The findings showed severe stenosis of the SMA origin with calcification, and the SMA had replaced the common hepatic artery (Fig. , ). ET, namely stenting to the SMA and common hepatic artery, was performed. The SMA trunk was engaged with a 6F Parent Plus 60 guiding catheter (Medikit, Tokyo, Japan) from the left brachial artery. Initially, 8000 units of heparin was infused, and additional heparin was added to keep the activated whole blood clotting time over 200 s. ", "role": "user" }, { "content": " The SMA occlusion was traversed using a 0. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 86-year old woman presented at the emergency department suffering from severe acute upper abdominal pain. Her past medical history included hypertension, diabetes mellitus, coronary heart disease, atrial fibrillation, chronic obstructive pulmonary disease and twenty years before she had an omphalocele repair. The patient was in a close clinical and radiological follow up for monitoring a pancreatic serous cystadenoma diagnosed incidentally with a computed tomography (CT) scan 10 years earlier. The lesion was extensively studied with magnetic resonance imaging (MRI), endoscopic ultrasound (EUS), fine needle aspiration (FNA), serology and blood test screening. At that time she was addressed for a routine year follow up scan which she attended regularly for six years. Patient did not attend her follow up time table for the last four years. Upon admission to the emergency department, chest and abdominal x-rays were performed and turned out inconclusive. Routine laboratory studies revealed marked leukocytosis, severe anemia, and blood glucose levels exceeding 500 mg/dl. Due to inconclusive diagnosis, an intravenous contrast CT scan was ordered and revealed a large amount of free peritoneal air and free fluid. (Figure , ) Moreover, a left upper quadrant 17 cm large mass originating from the stomach was revealed along with secondary liver lesions. An urgent laparotomy showed a prepyloric ulcer perforation and a large inoperable mass arising from the pancreatic body and largely invading the posterior wall of the stomach occupying the upper abdomen with multiple hepatic secondary lesions. A liver biopsy was taken, the stomach perforation was sutured closed and a washout was performed. The histopathologic findings from the biopsy material were consisted of small and medium size cystic lesions surrounded and divided by hyalloid collagenous matrix. The cysts w", "role": "user" }, { "content": " ere lined by cuboidal epithelial cells with clear <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 6-hour-old female neonate born from a 22-year-old Para 1 mother after term pregnancy. The newborn had protrusion of mass per vagina since birth; she also has a defect at the lower back with no discharge since the time of birth. Additionally the mother has noticed deformity on both legs and feet which barely move. The baby was active sinc", "role": "user" }, { "content": " e the time of delivery <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 63 year old man was referred from a primary health center with a penile lesio", "role": "user" }, { "content": " n of 8 months duration. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 59-year-old gentleman presented with a history of right iliac fossa mass. The CT scan showed a solid mass not obviously attached to the small or large bowel and had a possible fatty component at the edge (). The biopsy was reported as a malignant pleomorphic spindle cell lesion, which demonstrated strong positivity for SMA and desmin, whilst S100 and c-kit were negative. There was one mitosis per 10 hpf and no necrosis. Taking the radiological information into account, differential diagnosis of dedifferentiated liposarcoma with myogenic differentiation or a primary retroperitoneal leiomyosarcoma were suggested. Resection specimen received later comprised of a small bowel, the midpart of which was markedly distended by a pale mass measuring 14 × 11.5 cm. The nodular mass had a firm-cream yellow cut surface and approximately 60%–65% appeared to originate from the bowel wall. Several satellite lesions with similar macroscopic appearances were noted away from the main lesion.\nHistology showed the lesion to be composed of well-differentiated liposarcoma (atypical lipomatous tumour) with abrupt transition to areas with an extensive dedifferentiated component. The well-differentiated areas were represented by adipose tissue in which atypical adipocytes and lipoblasts were easily iden", "role": "user" }, { "content": " tifiable (Figures and ). <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 21-year-old nulliparous lady was referred to our emergency by a general practitioner at 28 weeks of gestation with history of abdominal pain since one week. There was no history of any discharge per vaginum, loss of fetal movements, abdominal trauma, or any bladder or bowel disturbance.\nShe was gravida two with one spontaneous abortion at 3 months of gestation about one year back, for which a curettage was done. Rest of her medical and surgical history was unremarkable. Her present pregnancy had been uneventful till now and her early pregnancy scans were reported to be normal.\nOn admission, her general condition was poor, and there were signs of hypotension and tachycardia. Her upper abdomen was soft and non tender while there was guarding and tenderness in lower abdomen. Her uterus was 26 weeks gravid, with contour well made out. Fetal parts were made out with difficulty. The flanks were dull on percussion. Fetal heart sounds could not be auscultated. On per speculum examination, there was no bleeding. Her vaginal examination revealed a soft cervix with os closed, and a firm round nontender 4×4cm mass in the anterior fornix toward the righ", "role": "user" }, { "content": " t side of cervix. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 12-year-old girl with a previous diagnosis of MFS was admitted in our Pediatric Surgery Unit with sudden onset of chest pain and shortness of breath after sneezing. Her past medical history revealed two previous left spontaneous pneumothorax (two and three months prior to this hospital admission), managed with conservative measures and pleural drainage.\nUpon examination, both physical and radiographic findings were compatible with a pneumothorax recurrence on the left side. A thoracic CT scan showed bullous pulmonary dysplasia (). Thoracoscopic treatment included resection of the pneumopleural adhesions and bullae. The procedure was performed with the patient in a lateral decubitus position. Three valved ports, ranging in size from 3 to 5 mm, were used. The first port was placed in the mid to the anterior axillary line in the fifth interspace to determine the position of the major fissure and evaluate the lung parenchyma. The position of the fissure dictates the placement of the other ports. The working ports were placed in the anterior axillary line above and below the camera port. Lung resection, including the parenchymal area involved in the lesion, was performed using the LigaSure® device. A lung specimen was removed using a protective specimen endobag through a 5 mm port. No postsurgical drainage tubes were positioned. The patient was discharged on the eighth postoperative day.\nOne week later, a pneumothorax recurrence necessitated a second thoracoscopic intervention. Further pulmonary resection of the atypical upper left lobe was performed using a stapling device. Two patches (9.5 × 4.8 cm) were cut from the adhesive/foam complex (TachoSil®), rolled and inserted into the 5 mm trocar, and subsequently stretched over the sutures. No drainage tubes were inserted. The postoperative period was uneventful, and the patient was discharged one week later. Gross findings showed severe emphysematous involvement in the upper lobe with marked bulla formation (). Microscopic examination revealed a characteristic e", "role": "user" }, { "content": " mphysema morphological pattern juxtap <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "In 2005, a 46-year-old woman presented with several years of progressive left jaw pain and swelling and ultimately developed partial left-sided facial paralysis. In August 2005, she underwent a left total parotidectomy with partial sacrifice of the left facial nerve. Histopathologic examination of the deep left parotid gland showed a thinly encapsulated low-grade salivary gland neoplasm. Tumor cells exhibited round to oval nuclei with inconspicuous nucleoli and basophilic granular cytoplasm that is characteristic of well-differentiated AcCC. Surgical margins were negative. In April 2008, the patient developed a local recurrence in the left neck, confirmed by fine needle aspiration. On May 29, 2008, she underwent surgical excision of the left neck mass with negative margins and one sampled lymph node negative for disease. No other treatment modalities were given. Two years later, the patient developed a second local recurrence, and in June 2010, a 5 × 3-mm mass consistent with recurrent AcCC was removed from the posterior triangle. In October 2010, a surveillance PET/CT scan revealed a 1-cm hypermetabolic nodule between the left styloid process and the tip of the mastoid. Fine-needle aspiration findings were consistent with a third local recurrence of AcCC. In January 2011, the patient had a left posterior neck exploration surgery with left neck dissection. Pathology revealed a single focus of recurrent disease in a lymph node measuring 2.6 cm. Surgical margins were negative but narrow at <0.1 cm. Three other lymph nodes sampled were negative for metastatic disease. The patient did not receive any adjuvant therapy an", "role": "user" }, { "content": " d was placed on expectant observation. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 28-year-old previously healthy female patient has attended our surgical clinic complaining of a chronic dull aching left-sided abdominal pain and mild abdominal distension for 1 year. During the course of investigations, she had an abdominal and pelvic CT scan and was found to have a 16.8 × 16 × 20 cm solid and cystic mass in the left retroperitoneum in the suprarenal area containing bone and multiple soft tissue densities (). The tumour had calcifications, was not well enhanced, and was without any evidence of distant metastasis. Further assessment was performed using abdominal magnetic resonance imaging (MRI) (). Preoperatively, we diagnosed the tumour as having originated in the left adrenal gland, because the normal adrenal gland could not be recognised by CT or MRI. Tumour markers, such as serum alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), lactate dehydrogenase (LDH), carcinoma antigen 125 (CA 125), neuron-specific enolase (NSE), and carbohydrate antigen 19-9 (CA 19-9), were examined because we also thought it might have been possible that the tumour did not originate from the adrenal gland.\nThe patient underwent resection of the lesion through a midline laparotomy approach. The retroperitoneal dissection was tedious and difficult, but the mass was excised in its entirety (). The macroscopic examination revealed a well-circumscribed mass measuring 230 mm × 200 mm × 120 mm, with intact surface. The specimen weighed in excess of 2 kg. The capsule was intact and the residual adrenal gland was noted on the external surface measuring 60 × 45 mm and was distinct from the mass. On slicing the specimen, t", "role": "user" }, { "content": " he mass was completely filled with sebaceous-like material <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "Our patient is 67-year-old Turkish man, a primary school graduate, and a forest ranger who lives in a rustic area. He was fully informed about the study and written consent was obtained from him prior to examination. In his medical examination he explained that his gums started bleeding at a very early age. At age 24, he started to smoke since he thought smoking would help to stop bleeding. Currently, he smokes 1-1.5 packs a day. At age 30, he started to experience difficulty in eating and complained of tooth mobility and gum bleeding. He claimed that his teeth ached a lot and as a result the teeth were extracted by a non-dentist or himself. Consequently, at the age of 50 to 60, he lost most of his teeth. At age 25, he was diagnosed with periodontitis. Nonetheless, he had not seen a dentist for this problem or perf", "role": "user" }, { "content": " ormed any personal oral hygiene. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "Our patient was female, almost six months old, the first child of unrelated, healthy Caucasian parents. The perinatal history was complicated by gestational diabetes. The girl was delivered on term via spontaneous vaginal labor at 36 weeks of pregnancy due to a premature rupture of membranes. Her birth weight was 2340 g and she received 9 points on the Apgar scale. There were no abnormalities in the healing of the umbilicus. The girl was rehabilitated from the beginning of the third month of life on account of increased muscle tone (hypertonia). Furthermore, she had an episode of acute diarrhea at three months of age, apart from which she did not suffer from any other illness. She was fully vaccinated by 6 months of age.\nThe patient presented with episodic diarrhea, intermittent “sun-setting eye phenomenon” and mild facial dysmorphism to a rural hospital where ultrasonography revealed hepatomegaly with numerous diffuse areas and decreased echogenicity, as well as failure to visualize the spleen twice. An echocardiogram disclosed atrial septal defect (ASD) type 2 and treatment with spironolactone was introduced. The structures of the brain were correctly visualized in a transcranial ultrasound. Moreover, family history of lupus erythematosus was only positive in the mother’s sister.\nThe patient was transferred to the hematology department due to high white blood cell count (WBC), increased hemoglobin and platelet count, with no abnormalities in the peripheral blood smear, accompanied by a suspicion of congenital asplenia. Due to the good clinical condition of the patient, but with a not high persistent WBC (up to 20 K/μl) and Hb (up to 17 g/dl), further scheduled diagnostics were planned. In addition, due to the suspicion of immunity disorders related to congenital asplenia, antibiotic prophylaxis (amoxicillin) and additional vaccinations against Streptococcus pneumoniae and Neisseria meningitidis were ordered, as we", "role": "user" }, { "content": " ll as a postponement of “live vaccinations”. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 40-year-old man presented with large plaques of 30 years duration over right upper limb, right side of the chest and back, and right lower limb. The lesion started as a small papule over right upper limb near the elbow when he was 10 years old. Since then it steadily grew in size to involve whole of the limb and also the right side of the chest and back. He developed similar lesions, one over the right thigh after about 2 years of the first lesion that gradually enlarged to involve most of the thigh circumferentially and one more lesion over the left side of the back since one year []. The lesions were asymptomatic except for mild itching. There was no history of trauma prior to the onset of the lesions or the past history suggestive of tuberculosis of any part of the body. There was no family history of tuberculosis or contact with a tuberculosis patient. He consulted many doctors and applied v", "role": "user" }, { "content": " arious creams but of no help. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 69-year-old male patient presented to our hospital due to visual loss and metamorphopsias on his left eye. Best corrected visual acuity (BCVA) at presentation was 9/10 in his right eye and 9/10 in his left eye with his hyperopic correction (+1.00 sph +0.50 cyl 180, OD, and +0.75 sph, OS). Slit lamp examination of the anterior segment and ocular motility examination did not reveal any significant abnormality. Fundus examination showed the presence of yellowish deposits (fleck-like) in the parafoveal area bilaterally and a grayish subretinal membrane was observed on the temporal side of the fovea of the left eye. Fundus autofluorescent images showed hyperautofluorescent deposits and a mottled loss of autofluorescence in the temporal parafoveal area of the left eye (). An occult choroidal neovascular membrane of the left eye was observed on fluorescein angiography that was subsequently obtained (). Optical coherence tomography scans of the macula showed focal RPE distortion on the right eye and the presence of intraretinal cysts and subretinal fluid on the temporal aspect of the fovea of the left eye (). The working diagnosis was that of a patient with the reticular type of pattern dystrophy, complicated by a leaking occult choroidal neovascular membrane of his left eye.\nDetailed information regarding the nature of his condition and the therapeutic options was given to the patient, but since the central visual acuity was not severely affected, he elected to be observed rather than receiving anti-VEGF intravitreal treatments. Repeat ophthalmic examination and OCT testing, 6 months later, revealed complete resolution of subretinal fluid and restoration of foveal architecture of the left eye (). Mean central macular thickness of the left eye decreased from 298 μm to 266 μm (at 6 months), ", "role": "user" }, { "content": " while macular thickness at the temporal side of <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 29-year-old man with no significant past medical hist", "role": "user" }, { "content": " ory presented to our outpatient clinic with worsening intermittent <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 28-year-old, active-duty military male with relapsed, refractory, metastatic, malignant, giant-cell-rich, primary bone sarcoma presented to the Emergency Department (ED) by cardiology instruction for evaluation of a large pericardial effusion with possible early tamponade physiology that was identified on an outpatient transthoracic echocardiogram (TTE). The echocardiogram was performed to further evaluate findings from a positron emission tomography (PET) scan completed three days prior that demonstrated findings concerning for cardiac metastasis to the interventricular septum with extension into the right ventricular outflow tract, along with an interval increase in the size of a pericardial effusion when compared to a PET scan from five months prior (Figure ). At the time of initial evaluation in the ED, the patient was asymptomatic from a cardiopulmonary standpoint, specifically denying chest pain or dyspnea, though endorsing chronic superficial abdominal tenderness in multiple abdominal regions. Vital signs were normal and physical examination was significant only for mild epigastric and right upper quadrant tenderness. An ECG was obtained that demonstrated sinus rhythm, low voltage, and anteroseptal myocardial injury (Figure ).\nIn the setting of ST-segment elevation, additional concern was raised by the discovery of hypokinesis of the septal myocardium on bedside echocardiogram, though it should be noted that this area of myocar", "role": "user" }, { "content": " dium was being impinged upon by <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "An 86-year-old multiparous Japanese woman with an unremarkable medical history was transferred to our hospital after a traffic accident (Table ). She was hit by a car while walking at a crosswalk. On presentation to our emergency department, she compl", "role": "user" }, { "content": " ained of pain in her buttock. <\|endoftext\|>", "role": "assistant" } ]
[ { "content": "A 29 yr old woman at 27+5 weeks gestation (gravida 1, para 0) was hospitalized due to dyspnea (NYHA IV) which had started 10 days before. The patient was healthy in the past, and the prenatal care findings of the local clinic were nonspecific. According to physical examination, dyspnea was aggravated at the inspiratory phase and right decubital position. Blood pressure was 120/80 mmHg, and her pulse rate evidenced tarchycardia of 120 beats/min. Both of her neck veins were engorged.\nRoutine blood tests and chest radiography were performed, but resulted in no peculiarity. Transthoracic echocardiography revealed a 5 cm in diameter echogenic mass spreading from the anterior of the left atrium to the mitral leaflet and mitral annulus, severe eccentric mitral regurgitation coupled with severe stenosis, and severe pulmonary hypertension (). The fetus was at a size consistent with IUP 27+2 weeks, according to obstetric sonography, and appeared to be normal. The patient was given intramuscular dexamethasone, 5 mg every 12 hr for 4 doses.\nThe operation on the intracardiac mass was carried out via median sternotomy. Continuous fetal heart rate and uterine monitoring were performed using cardiotocography throughout the procedure. On the area connecting the sternal body and the xiphoid process, we found a tumor mass about 2 cm in diameter. A diagnosis by frozen section identified the mass as sarcoma. We began normothermic cardiopulmonary bypass. The mass originating from the atrioventricular wall was found to have ", "role": "user" }, { "content": " spread all the way to the <\|endoftext\|>", "role": "assistant" } ]

Subsets and Splits

No community queries yet

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